Impact of Australian mandatory ‘No Jab,No Pay’ and ‘No Jab,No Play’ immunisation policies on immunisation services,parental attitudes to vaccination and vaccine uptake,in a tertiary paediatric hospital,the Royal Children’s Hospital,Melbourne

Introduction‘No Jab, No Play’ and ‘No Jab, No Pay’ mandatory immunisation policies were introduced in the state of Victoria and Australia-wide, respectively, in January 2016. They restrict access to childcare/kindergarten and family assistance payments respectively, for under-vaccinated children. We aimed to describe the proportion of attendees to immunisation services of a tertiary hospital, the Royal Children’s Hospital Melbourne (RCH), who were motivated by the policies to discuss or catch-up vaccination. We explored the association between motivation by policies, vaccine hesitancy (VH) and intent to seek medical exemption, with vaccine-uptake.MethodsParents/Guardians and clinicians completed surveys October 2016-May 2017 from the nurse-led immunisation Drop in Centre (DIC) or physician-led Specialist Immunisation Clinic (SIC). Vaccine-uptake was measured using the Australian Immunisation Register (AIR) at baseline, 1 and 7 months post-attendance. The association between vaccine-uptake, motivation by policies and VH was explored by logistic regression.ResultsOf 607 children, 393 (65%) were from the DIC and 214 (35%) SIC. 74 (12%) parents were motivated by the policies to attend immunisation services and 19% were VH. Only 50% of VH parents planned to catch-up vaccination for enrolment to childcare/kindergarten. Seven months post-attendance there was no association between motivation by policies and full vaccination status (difference 10%, OR 0.42, CI 0.17–1.1, p 0.08). Fewer children were fully immunised at 7 months if their parents were VH (difference 18%; OR 0.24, CI 0.1–0.54, p < 0.001) or seeking medical exemption (difference 33%, OR 0.08, CI 0.01–0.6, p 0.015).ConclusionThe ‘No Jab’ policies motivated attendance to a tertiary immunisation service. However, children of vaccine hesitant parents and those seeking medical exemption to immunisation were less likely to be fully immunised after attendance, than at baseline. The ‘No Jab’ policies may not be changing vaccination behavior as intended for vaccine hesitant parents who are one of the key target groups, with further evaluation required.     

Parental opinions towards the “No Jab,No Pay” policy in Australia

BackgroundIn 2016, Australia introduced the “No Jab, No Pay” legislation, which removed the option of non-medical exemptions from the vaccination requirements to receive certain family and child care tax benefits. We aimed to gauge parental support for “No Jab, No Pay” and explore how it has impacted parental attitudes towards vaccination, particularly among families that are reliant on the tax benefits linked to vaccination under “No Jab, No Pay”.MethodsAn online survey distributed to parents with children under 5 in Australia assessed parental knowledge and opinions towards childhood vaccination and the “No Jab, No Pay” policy.ResultsA total of 411 parents completed the survey. The majority of parents reported their child was either fully vaccinated or they intended to fully vaccinate. Eighty-two percent of parents were in favour of “No Jab, No Pay.” The belief that vaccine-preventable diseases are a significant risk to unvaccinated children was a predictor of supporting the “No Jab, No Pay” policy (AOR = 5.95, 95% CI = [3.60, 10.94], p < 0.001). Parents that depend on the financial benefits associated with “No Jab, No Pay” and parents that utilize child care services were significantly more likely to reconsider vaccination, if they previously hesitated or objected, because of the policy (AOR = 9.66, 95% CI = [4.98, 18.72], p < 0.001 and AOR = 2.09, 95% CI = [1.04, 4.17], p = 0.04).ConclusionWe found that there is widespread support for “No Jab, No Pay” among parents of young children, but parents that depend on the financial benefits or utilize child care services may be disproportionately affected by the policy. Childhood vaccination coverage in Australia could best be improved by increasing access to vaccination services and by imposing significant administrative barriers to obtaining non-medical exemptions.     

Evaluation of a school entry immunization record check strategy in 4 counties of Ningxia and Hubei provinces,China

China has a national requirement that children's vaccination status is to be checked upon entry to kindergarten and school; children who have missed vaccine doses are to be referred to vaccination clinics to receive the necessary vaccinations. Most provinces have Immunization Information Systems (IIS) that contain and manage vaccination records of children served by immunization clinics. We conducted an evaluation in Hubei and Ningxia provinces using IIS data to determine the effect of their school entry immunization record checking strategy (SECS) on vaccination coverage and rate of catch-up for selected vaccines.We selected two counties with well-functioning IISs from each province. Names and demographic information of children enrolled in 185 kindergartens and 125 primary school in 2016 were used to identify children in the IIS and obtain their vaccination records. We calculated vaccination coverage before and after implementation of the SECS and determined catch-up rates for 5 vaccines, of which 3 are given before 2 years of age and 2 are given after 2 years of age.Among the 20,215 newly-enrolled children, 75% were able to be matched with IIS records. Few children who had missed one or more doses of the 3 vaccines recommended in the first two years of life received catch-up doses after SECS. For vaccines scheduled after 2 years of age, there was a statistically significant (p < 0.05) coverage increase in both provinces following the school-entry record check. Among children who were age-eligible for the selected vaccines before SCES, the catch-up rate was <50%.SECS provides opportunities to identify incompletely vaccinated children, improve coverage, and remind families of school-age children about up-coming vaccinations; SECS has potential to improve completeness of IIS data and enrollment of children in immunization clinics. Evidence-based policy with implementation guidance and routine monitoring are necessary to improve China’s school entry checking strategy.     

The associations between medical,allied and complementary medicine practitioner visits and childhood vaccine uptake

BackgroundVaccination rates have remained steady for a number of years in Australia, however geographical areas of lower vaccine coverage remains a day-to-day challenge. The study explores parental attitudes, beliefs and intentions in relation to vaccination and examines the early effects of recent No Jab No Pay legislation.MethodsA national survey of was conducted, using an online questionnaire. Parents from all states in Australia with at least one child aged <6 years were invited to participate.ResultsA total of 429 parents participated in the study. The substantial majority of participants reported having their youngest child's vaccination status up to date (n = 401, 93.5%). A child’s vaccinations were more likely to be up to date if they had consulted a paediatrician in the previous 12-months (OR 5.01; 95%CI 1.05, 23.92; p = .043). Conversely they were less likely to be vaccinated if they were influenced by information from a complementary medicine (CM) practitioner (OR 0.03; 95%CI 0.01, 0.15; p < .001) or had visited a CM-practitioner (OR 0.09; 95%CI 0.02, 0.33; p < .001) in the previous 12-months. A total of 2.6% of parents had immunised their child as a result of the No Jab No Pay legislation, while 3.9% stated the legislation had no effect, and 1.2% said it had made them less likely to vaccinate. A further 1.2% of parents stated they are considering vaccination as a result of the legislative changes.ConclusionParents who have not vaccinated their children appear to trust non-mainstream sources of information such as CM-practitioners. Further research is required to determine how to manage the challenges and opportunities of CM-practitioners as a source of vaccine information.     

Application of the theoretical domains framework to identify factors influencing catch-up HPV vaccinations among male college students in the United States: A review of evidence and recommendations

BackgroundGenital human papillomavirus (HPV) infection is the most prevalent sexually transmitted infection among young adults ages 15–25 years in the United States (US). Although HPV vaccines are recommended for individuals ages through 26 years, vaccine completion rates remain substantially low.MethodsAccordingly, our study utilized a comprehensive – Theoretical Domains Framework (TDF) of behavior change to systematically identify facilitators and barriers to catch-up HPV vaccinations. Five databases - Medline, Embase, CINAHL, ERIC, and PsycINFO were searched from January 2009 to July 2019 for empirical studies using quantitative and qualitative methods to assess HPV vaccine uptake among males ages 18–26 years within US college and university settings. The TDF analytic process included a content analysis using the mixed deductive-inductive approach to extract, analyze and categorize data into TDF domains/themes and sub-themes.ResultsOverall, 17 studies were selected for data extraction. We identified eleven key TDF domains that influenced HPV vaccination behavior among college male students: ‘knowledge’ (82% of included studies), ‘environmental context and resources’ (53%), ‘beliefs about consequences’ (53%), ‘unrealistic optimism’ (50%) and ‘pessimism’ (6%), ‘emotion’ (50%), ‘social influences’ (50%), ‘beliefs about capabilities’ (41%), ‘intention’ (24%), ‘reinforcement’ (18%), ‘social professional role and identity’(12%), and ‘behavioral regulation’ (12%). Barriers influencing HPV vaccine uptake included lack of knowledge and awareness regarding HPV infections, HPV vaccine safety, effectiveness, side effects, and costs; absence of health providers’ recommendations; lack of healthcare and health insurance; low levels of perceived susceptibility and severity for HPV infections; HPV vaccine misinformation; as well as social stigma and peer influences regarding HPV vaccinations. Enablers for HPV vaccine uptake included high levels of perceived benefits for HPV vaccines.DiscussionOur study theoretically identified factors influencing HPV vaccinations. This could inform the efficient planning, support, and implementation of interventions that facilitate catch-up HPV vaccination practices among high-risk males within college/university settings.     

Variability in influenza vaccination opportunities and coverage among privately insured children

BackgroundUniversal influenza vaccination has been recommended since 2010, yet influenza vaccination rates among children aged 6 months to 17 years remain low compared with other routinely recommended childhood vaccines.ObjectiveAssess in-plan vaccination coverage, opportunities, and missed opportunities during the 2016–2017 influenza season.Study Design:Retrospective analyses using 2016–2017 MarketScan® data for 2,768,799 privately insured children aged 1–17 years by the end of 2016 who were continuously enrolled in the same insurance plan during the 2016–2017 influenza season (defined as August 1, 2016 through May 31, 2017). We assessed in-plan vaccination coverage (percentage receiving ≥ 1 dose of influenza vaccine from August 2016-May 2017) and vaccination opportunities (percentage with ≥ 1 provider visit between September 2016 – May 2017). Among children who remained unvaccinated at the end of the season, those with ≥ 1 influenza vaccination opportunity between September 2016-May 2017 were determined to have a missed opportunity.ResultsIn-plan vaccination coverage during the 2016–17 season was 67.7% in infants (born 2015), 49.5% in toddlers (born 2012–2014), 35.0% in school-aged children (born 2004–2011), and 22.3% in teenagers (born 1999–2003). Like vaccination coverage, vaccination opportunities decreased with age (infants: 97.7%, toddlers: 91.9%, school-aged children: 82.6%, teenagers: 79.3%). Among unvaccinated children, 93.1%, 84.1%, 73.6% and 73.6% of each age group had a missed opportunity for influenza vaccination.ConclusionOpportunities for and coverage with influenza vaccination vary even among privately insured children. Along with continued efforts to reduce missed opportunities, effective strategies to bring children to their doctor for annual influenza vaccination are needed, particularly for older children.     

A randomised controlled trial of SMS messaging and calendar reminders to improve vaccination timeliness in infants

BackgroundThe effectiveness of SMS reminders in improving vaccination coverage has been assessed previously, with effectiveness varying between settings. However, there are very few studies on their effect on the timeliness of vaccination.DesignUnblinded, randomised controlled trial with blocked sampling.Methods1594 Australian infants and young children were recruited to assess the impact of (1) SMS reminders only, (2) a personalised calendar, (3) SMS reminder and personalised calendar and (4) no intervention, on receipt of vaccine within 30 days of the due date. Outcomes were measured for receipt of vaccines due at 2, 4, 6, 12 and 18 months of age. A post-hoc assessment was also conducted of the impact of a new national “No jab No Pay” policy introduced during the trial, which removed philosophical objections as an exemption for financial penalties for non-vaccination.ResultsThere was a statistically significant improvement in on-time vaccination only at the 12 month schedule point amongst infants who received SMS reminders alone (RR 1.09, 95% CI 1.01–1.18) or in combination with a personalised calendar (1.11, CI 1.03–1.20) compared to controls. This impact was limited to participants who had received one or more previous doses late. No statistically significant impacts of calendar interventions alone were seen. There was a high rate of on-time compliance amongst control participants − 95%, 86%, 80%, 74% at the 4, 6, 12 and 18 month schedule points respectively, which increased more than 10 percentage points after implementation of the “No Jab, No Pay” policy.ConclusionsSMS reminders are more effective in improving timeliness where pre-existing compliance is lower, but the 18 month schedule point appeared to be less amenable to intervention. Australia and New Zealand Clinical Trial Registration No. ACTRN12614000970640.     

Vaccine mandates on childcare entry without conscientious objection exemptions: A quasi-experimental panel study

ObjectivesExamine the effect of No Jab No Play policies, which linked vaccine status to childcare service entry without allowing for personal belief exemptions, on immunisation coverage.Study designImmunisation coverage rates from the Australian Immunisation Register were linked to regional level covariates from the Australian Bureau of Statistics between January 2016 and December 2019. Differential timings of policy rollouts across states were used to assess changes in coverage with the implementation of policies with generalised linear models. Quantile regression and subgroup analysis were also conducted to explore the variation in policy responses.ResultsBaseline mean vaccination rates in 2016 were 93.4% for one-year-olds, 91.2% for two-year-olds and 93.2% for five-year-olds. Increases in coverage post-policy were significant but small, at around 1% across age groups, with larger increases in two and five-year-olds. Accounting for aggregate time trends and regional characteristics, implementation of the policies was associated with improved full immunisation coverage rates for age one (post-year 1: 0.15% [95 %CI–0.23; 0.52]; post-year 2: 0.56% [95 %CI 0.05; 1.07]), age two (post-year 1: 0.49 [95 %CI: 0.00; 0.97]; post-year 2: 1.15% [95 %CI: 0.53; 1.77], and age five (post-year 1: 0.38% [95 %CI 0.08; 0.67]; post-year 2: 0.71% [95 %CI 0.25; 1.16]. The policy effect was dispersed and insignificant at the lowest quantiles of the distribution of immunisation coverage, and smaller and insignificant in the highest socioeconomic areas.ConclusionFindings suggest that No Jab No Play policies had a small positive impact on immunisation coverage. This policy effect varied according to prior distribution of coverage and socio-economic status. Childcare access equity and unresponsiveness in high socioeconomic areas remain concerns.     

Stop measles in Switzerland – The importance of travel medicine

BackgroundIn line with the worldwide strive to combat measles, the Swiss Federal Office of Public Heath (FOPH) launched a National Strategy for measles elimination 2011–2015. In this study, we highlight the importance of travel medicine consultations to complement measles vaccination programmes based on data from the Travel Clinic of the University of Zurich.MethodWe analysed measles vaccination data from the Zurich Travel Clinic between July 2010 and February 2016 and focused on three groups: (i) all clients who received the measles vaccination, (ii) all clients aged > two years who received the measles vaccination (“catch-up vaccination”), and (iii) all clients aged > two years and born after 1963 (“FOPH recommended catch-up vaccination”).Results107,669 consultations were performed from 2010 to 2016. In 12,470 (11.6%) of these, a measles vaccination was administered; 90.9% measles vaccinations were given during a pre-travel consultation, and 99.4% were administered to individuals aged > two years (“catch-up vaccinations”). An “FOPH recommended catch-up vaccination” was received by 13.6% of all Zurich Travel Clinic clients aged >2 years and born after 1963.ConclusionsIn this study, we highlight the importance of travel medicine consultations to enhance the measles vaccination coverage in the adult Swiss population.     

Cost-effectiveness of routine catch-up hepatitis a vaccination in the United States: Dynamic transmission modeling study

BackgroundDespite routine vaccination of children against hepatitis A (HepA), a large segment of the United States population remains unvaccinated, imposing a risk of hepatitis A virus (HAV) to adolescents and adults. In July of 2020, the Advisory Committee on Immunization Practices recommended that all children and adolescents aged 2–18 years who have not previously received a HepA vaccine be vaccinated. We evaluated the public health impact and cost-effectiveness of this HepA catch-up vaccination strategy.MethodsWe used a dynamic transmission model to compare adding a HepA catch-up vaccination of persons age 2–18 years to a routine vaccination of children 12–23 months of age with routine vaccination only in the United States. The model included various health compartments: maternal antibodies, susceptible, exposed, asymptomatic infectious, symptomatic infectious (outpatient, hospitalized, liver transplant, post- liver transplant, death), recovered, and vaccinated with and without immunity. Using a 3% annual discount rate, we estimated the incremental cost per quality-adjusted life year (QALY) gained from a societal perspective over a 100-year time horizon. All costs were converted into 2020 US dollars.FindingsCompared with the routine vaccination policy at 12–23 months of age over 100 years, the catch-up program for unvaccinated children and adolescents aged 2–18 years, prevented 70,072 additional symptomatic infections, 51,391 outpatient visits, 16,575 hospitalizations, and 413 deaths. The catch-up vaccination strategy was cost-saving when compared with the routine vaccination strategy. In scenario analysis allowing administering a second dose to partially vaccinated children, the cost-effectiveness of was not favorable at a higher vaccination coverage ($196,701/QALY at 5% and $476,241/QALY at 50%).InterpretationHepA catch-up vaccination in the United States is expected to reduce HepA morbidity and mortality and save cost. The catch-up program would be optimized when focusing on unvaccinated children and adolescents and maximizing their first dose coverage.     

Cost-effectiveness analysis of catch-up hepatitis A vaccination among unvaccinated/partially-vaccinated children

BackgroundSince 2006, the US Centers for Disease Control and Prevention has recommended hepatitis A (HepA) vaccination routinely for children aged 12–23 months to prevent hepatitis A virus (HAV) infection. However, a substantial proportion of US children are unvaccinated and susceptible to infection. We present results of economic modeling to assess whether a one-time catch-up HepA vaccination recommendation would be cost-effective.MethodsWe developed a Markov model of HAV infection that followed a single cohort from birth through death (birth to age 95 years). The model compared the health and economic outcomes from catch-up vaccination interventions for children at target ages from two through 17 years vs. outcomes resulting from maintaining the current recommendation of routine vaccination at age one year with no catch-up intervention.ResultsOver the lifetime of the cohort, catch-up vaccination would reduce the total number of infections relative to the baseline by 741 while increasing doses of vaccine by 556,989. Catch-up vaccination would increase net costs by $10.2 million, or $2.38 per person. The incremental cost of HepA vaccine catch-up intervention at age 10 years, the midpoint of the ages modeled, was $452,239 per QALY gained. Across age-cohorts, the cost-effectiveness of catch-up vaccination is most favorable at age 12 years, resulting in an Incremental Cost-Effectiveness Ratio of $189,000 per QALY gained.ConclusionsGiven the low baseline of HAV disease incidence achieved by current vaccination recommendations, our economic model suggests that a catch-up vaccination recommendation would be less cost-effective than many other vaccine interventions, and that HepA catch-up vaccination would become cost effective at a threshold of $50,000 per QALY only when incidence of HAV rises about 5.0 cases per 100,000 population.     

Geographic proximity to immunization providers and vaccine series completion among children ages 0–24 months

ObjectivesIn the U.S., vaccination coverage is lower in rural versus urban areas. Spatial accessibility to immunization services has been a suspected risk factor for undervaccination in rural children. Our objective was to identify whether geographic factors, including driving distance to immunization providers, were associated with completion of recommended childhood vaccinations.MethodsWe analyzed records from Montana’s immunization information system for children born 2015–2017. Using geolocated address data, we calculated distance in road miles from children’s residences to the nearest immunization provider. A multivariable log-linked binomial mixed model was used to identify factors associated with completion of the combined 7-vaccine series by age 24 months.ResultsAmong 26,085 children, 16,503 (63.3%) completed the combined 7-vaccine series by age 24 months. Distance to the nearest immunization provider ranged from 0 to 81.0 miles (median = 1.7; IQR = 3.2), with the majority (92.1%) of children living within 10 miles of a provider. Long distances (>10 miles) to providers had modest associations with not completing the combined 7-vaccine series (adjusted prevalence ratio [aPR]: 0.97, 95% confidence interval [CI]: 0.96–0.99). After adjustment for other factors, children living in rural areas (measured by rural-urban commuting area) were significantly less likely to have completed the combined 7-vaccine series than children in metropolitan areas (aPR: 0.88, 95% CI: 0.85–0.92).ConclusionsLong travel distances do not appear to be a major barrier to childhood vaccination in Montana. Other challenges, including limited resources for clinic-based strategies to promote timely vaccination and parental vaccine hesitancy, may have greater influence on rural childhood vaccination.     

Herpes zoster vaccine coverage in Australia before and after introduction of a national vaccination program

BackgroundIn Australia, a herpes zoster (HZ) vaccination program targeting adults aged 70 years old with catch-up for those 71-79 years began in November 2016 but there is limited information on vaccine uptake and coverage achieved since commencement.MethodsWe used a national de-identified electronic primary care dataset, MedicineInsight, and extracted records from patients turning 50–90 years old during 2016–2018. Among patients considered regular attenders, with at least one visit per year in the two years prior, we estimated the crude and adjusted average monthly HZ vaccine uptake in the target population (70–79 years old) for each year since program implementation as well as cumulative vaccine coverage until December 2018. Multivariate logistic regression was used to analyse characteristics associated with higher coverage.ResultsAmong 52,229, 55,034, and 57,316 regular attenders turning 70–79 years old in 2016, 2017 and 2018 respectively, the average monthly vaccine uptake rate was 5.5%, 3.3%, and 1.6% respectively. Up to 31st December 2018, the estimated cumulative vaccine coverage in regularly attending adults was 46.9% (25,791/55,034). It was substantially lower at 41.6% (27,040/65,010) using an alternate definition of a regular attender. Vaccine coverage differed by sex (women: 48.5% versus men: 45.1%, adjusted OR = 1.1, 95% CI: 1.1–1.2); by jurisdiction (compared to New South Wales: 43.7%, South Australia: 55.6%, aOR = 1.6, 95% CI (1.5–1.8); Northern Territory: 27.6%, aOR = 0.6, (0.5–0.7)); by remoteness status (compared to major cities: 47.6%, remote/very remote areas: 38.2%, aOR = 0.7, (0.6–0.8)); and by socioeconomic disadvantage (compared to most disadvantaged: 41.8%, most advantaged: 48.6%, aOR = 1.6 (1.2–2.1)).ConclusionsOur estimates of HZ vaccine coverage are substantially higher than the only other reports based on the Australian Immunisation Register however they still suggest that uptake is suboptimal. The use of electronic medical records can complement other data for estimating vaccine coverage in Australian adults.     

Vaccination coverage among young homeless children compared to US national immunization survey data

IntroductionComprehensive vaccination coverage among homeless children in the United States (US) is largely unknown although a few studies suggest low coverage with single vaccinations. This study compared vaccination coverage with a combined 7-vaccines series among homeless children in the District of Columbia (DC) to coverage among other US children.Materials and methodsA cross-sectional survey of homeless children in DC was conducted from 2018 to 2019. Recruitment occurred at housing shelters, social services centers, and a diaper dispensary, and through limited chain referral. English-speaking parents of a child aged 19 to 35 months who spent the majority of the last 30 nights homeless were recruited. Participants consented for their child’s healthcare providers to submit vaccination records. The vaccination coverage estimate of this sample was compared with estimates of three populations in the 2018 National Immunization Survey (NIS): children in DC (NIS DC), children in the US (NIS US), and children in the US below the federal poverty level (NIS poor).ResultsMost of the 135 children had experienced at least two lifetime episodes (63.7%) and 12 months (57%) of homelessness. The estimated percent up to date was 52.6% (95% CI: 43.8%, 61.3%). This estimate was 20.4 (95% CI: 11.9, 28.8, p < .0001), 20 (95% CI: 11.5, 28.4, p < .0001), and 11.5 (95% CI: 3.1, 20, p < .01) percentage points lower than estimates for the NIS DC, NIS US and NIS poor populations, respectively. After adjusting for child’s age and race/ethnicity, vaccination coverage of the NIS DC sample was below that of NIS US (p < .01) and NIS poor samples (p < .05).ConclusionChildren experiencing homelessness may be at risk of under-vaccination, even when compared to a general population of children in poverty. Awareness of this heightened risk may allow for more precise targeting of vaccination delivery support specifically to children experiencing homelessness.     

Rural,urban, and suburban differences in influenza vaccination coverage among children

Influenza vaccination is the primary way to prevent influenza, yet influenza vaccination coverage remains low in the United States. Previous studies have shown that children residing in rural areas have less access to healthcare and lower vaccination coverage for some vaccines. Influenza vaccination coverage among children 6 months–17 years by rural/urban residence during the 2011–12 through 2018–19 influenza seasons was examined using National Immunization Survey-Flu data. The Council of American Survey Research Organizations response rates for National Immunization Survey-Flu ranged from 48% to 65% (2011–12 through the 2017–18 seasons) for the landline sample and 20%–39% (2011–12 through the 2018–19 seasons) for the cellular telephone sample. Children residing in rural areas had influenza vaccination coverage that ranged from 7.9 (2012–13 season) to 12.6 (2016–17 season) percentage points lower than children residing in urban areas, and ranged from 4.5 (2012–13 season) to 7.4 (2016–17 season) percentage points lower than children residing in suburban areas. The differences in influenza vaccination coverage among rural, suburban, and urban children were consistent over the eight seasons studied. Lower influenza vaccination coverage was observed among rural children regardless of child’s age, mother’s education, household income, or number of children under 18 years of age in the household. Rural versus urban and suburban differences in influenza vaccination coverage remained statistically significant while adjusting for selected sociodemographic characteristics. A better understanding of the reasons for lower childhood influenza vaccination coverage for children in rural and suburban areas is needed.     

Prevalence of human papillomavirus in teenage heterosexual males following the implementation of female and male school-based vaccination in Australia: 2014–2017

BackgroundAustralia introduced a school-based human papillomavirus (HPV) vaccination program for females aged 12–13 years in 2007, with a three-year catch-up to age 26; and for boys aged 12–13 from 2013, with a two-year catch-up to age 15. This study aimed to compare the prevalence of penile HPV between teenage heterosexual males in cohorts eligible or non-eligible for the school-based male vaccination program.MethodsBetween 2014 and 2017, sexually active heterosexual males aged 17–19 were recruited from sexual health centres and community sources across Australia. Males provided a self-collected penile swab for 37 HPV genotypes using Roche Linear Array and completed a questionnaire. We calculated adjusted prevalence ratios (aPR) of HPV between males in two periods: 2014–2015 (preceding implementation of school-based male vaccination) and 2016–2017 (eligible for school-based male vaccination). Self-reported vaccine doses were confirmed with doses reported to the National HPV Vaccination Program Register.ResultsOverall, 152 males were recruited in 2014–2015 and 146 in 2016–2017. Numbers of female sex partners and condom use did not differ between the two periods. The prevalence of quadrivalent vaccine-preventable [4vHPV] genotypes (6/11/16/18) was low in both periods (2.6% [2014–15] versus 0.7% [2016–17]; p = 0.371; aPR 0.28 [95% CI: 0.03–2.62]). Compared with men in 2014–2015, men in 2016–2017 had a lower prevalence of any of the 37 HPV genotypes tested (21.7% versus 11.6%; aPR 0.62 [95% CI: 0.36–1.07]) and any of the 13 high-risk genotypes tested (15.8% versus 7.5%; aPR 0.59 [95% CI: 0.30–1.19]). Prevalence of low-risk HPV genotypes did not differ between the two periods. Of the males recruited in 2016–2017, 55% had received ≥1 vaccine dose.ConclusionThe prevalence of 4vHPV genotypes among teenage heterosexual males in both cohorts was low, presumably due to herd protection from the female-only vaccination program. Further studies are required to determine the impact of universal HPV vaccination on HPV prevalence in males.     

Understanding what people think and feel about adult vaccinations and the associated barriers in Greece: Development and validation of the attitude towards adult vaccination (ATAVAC) scale

Despite the unequivocal value of vaccination in reducing the global burden of infectious diseases, the anti-vaccination movement thrives. The vast majority of the existing validated tools explore attitudes regarding vaccination in children. The aim of our study was to develop and validate a scale assessing attitudes towards adult immunisation. This national cross-sectional study included adult healthcare users who visited 23 Greek Primary Healthcare Units. The development of the scale was the result of literature review, semi-structured interviews and pilot testing of its preliminary versions. The initial version contained 15 items measuring respondents’ attitudes on a 6-point Likert scale. The sample was randomly split into two halves. Exploratory factor analysis, performed in the first sample, was used for the creation of multi-item scales; confirmatory factor analysis was used in the second sample to assess goodness of fit. Moreover, concurrent validity, internal consistency reliability, test–retest reliability and ceiling and floor effects were explored. The total sample consisted of 1,571 individuals. Overall ‘Cronbach's alpha’ (0.821) indicated good internal consistency. The initial exploratory factor analysis resulted in a three-factor model. The subsequent confirmatory factor analysis indicated that an 11-item version of the scale provided the best fit of the model to the data (RMSEA = 0.050, SRMR = 0.053, TLI = 0.937, CFI = 0.955, AIC = 24,999.949). All subscales (‘value of adult vaccination’, ‘safety concerns’ and ‘perceived barriers’) demonstrated strong concurrent associations with participants’ attitudes and behaviour regarding vaccination (p < .001). No ceiling or floor effects were noted for any of the subscales (0.13%, 2.61% and 0.51%; 0.13%, 0.57% and 0.45% respectively). The 11-item ATAVAC scale proved to be a reliable and valid tool, suitable for assessing attitudes towards adult vaccination.     

Influenza vaccination rates in children decline when the live attenuated influenza vaccine is not recommended

BackgroundIn 2016 the Centers for Disease Control and Prevention (CDC) recommended against using the live attenuated influenza vaccine (LAIV) for the 2016–2017 influenza season. This recommendation is potentially important for vaccination rates because perceived effectiveness and ease of administration are among the primary determinants of families decisions to vaccinate their children. This investigation sought to determine whether rates of pediatric influenza vaccination changed in a season when the LAIV was not recommended.MethodsThis study used cohort and cross sectional data from an academic primary care pediatric center in central Pennsylvania that serves approximately 12,500 patients. Early season (prior to November 1) and end-of-season (prior to March 1) vaccination rates in the 2015–16 and 2016–17 influenza seasons were recorded for individuals 2–17 years old. Repeat vaccination rates (percentage of children receiving influenza vaccination in one season who were also vaccinated in the next season) were recorded for the 2015–16 into 2016–17 seasons. A logistic regression model adjusting for race, ethnicity, age, insurance type and type of vaccination received was employed to identify predictors of repeat vaccination.ResultsIn the absence of LAIV (2016–17) early vaccination rates were significantly higher (24.7% vs 22.8%, p = 0.004), but end-of-season rates were lower (50.4% vs 52.0%, p = 0.03) than when LAIV was offered (2015–16). After adjusting for covariates, those who had received IIV in the 2015–16 season had higher odds (OR 1.32, 95% CI, 1.15–1.52) of getting a repeat vaccination in the 2016–17 season, compared with those who had received LAIV in the 2015–16 season.ConclusionsEnd-of-season vaccination rates were lower in 2016–17 when LAIV was not recommended, particularly among children who received LAIV in the preceding year. Unavailability of LAIV in the 2016–17 season may have impacted influenza vaccination convenience and perceived effectiveness, two factors which could influence vaccine uptake in pediatric populations.