Maternal immunization in Argentina: A storyline from the prospective of a middle income country

The importance of vaccination during pregnancy lies not only in directly protecting vaccinated women, but also by indirectly protecting small infants during the first few months of life. Vaccination against the flu and whooping cough is a priority within the comprehensive care strategy for pregnant women and small infants in Argentina, in the context of transitioning from child vaccination to family vaccination.In 2011, the flu vaccine was included in the National Immunization Schedule (NIS) as mandatory and free of charge, with the aim of decreasing complications and death due to influenza in the at-risk population in Argentina. The national vaccination coverage attained in pregnant women in the past 4 years (2011–2014) has been satisfactory; 88% coverage was attained in the year this program was introduced to the schedule. In the following years, coverage was maintained at greater than 95%. In February 2012, Argentina became the first country in Latin America to have universal vaccination strategy for pregnant women against whooping cough. This recommendation was implemented throughout the country by vaccination with the diphtheria toxoid, tetanus toxoid, and acellular pertussis (Tdap) vaccine starting at 20 weeks of pregnancy, with the aim of decreasing morbimortality due to whooping cough in infants under 6 months of age. The vaccine was incorporated into the NIS in 2014. More than 1,200,000 doses were applied in this period. Both vaccines showed a suitable safety profile and no serious events were reported.Argentina is an example of a middle-income country that has been able to implement a successful strategy for primary prevention through vaccines, making it a health policy.     

The Addis Declaration on Immunization: A binding reminder of the political support needed to achieve universal immunization in Africa

While African countries have improved access to immunization since the start of the millennium, progress has stagnated in the last few years. One in five African children is not vaccinated with life-saving vaccines, and recent outbreaks of vaccine-preventable diseases (VPDs) including yellow fever, measles, and meningitis, among others point to gaps in immunization coverage as well as disease surveillance.In 2017, African Heads of State endorsed the Addis Declaration on Immunization (ADI) at the 28th African Union Summit and committed to ensuring universal access to immunization across the continent. Since then, countries have taken several steps to translate the ADI commitments into tangible progress. However, the continent continues to face challenges in delivering immunization services, including limited vaccine-related funding, inequitable access to immunization services and weak surveillance systems. In the absence of concerted political will, COVID-19 threatens to reverse progress made so far.This paper reflects on the effects of political will in shaping the immunization agenda on the continent and the continued need for political commitment to deliver on the ADI commitments in a post-COVID world. Data were gathered from the regular national immunization reports, WHO/UNICEF estimates of immunization coverage as well as case studies of country implementation on ADI.     

Improving the quality and use of immunization and surveillance data: Summary report of the Working Group of the Strategic Advisory Group of Experts on Immunization

Concerns about the quality and use of immunization and vaccine-preventable disease (VPD) surveillance data have been highlighted on the global agenda for over two decades. In August 2017, the Strategic Advisory Group of Experts (SAGE) established a Working Group (WG) on the Quality and Use of Global Immunization and Surveillance Data to review the current status and evidence to make recommendations, which were presented to SAGE in October 2019.The WG synthesized evidence from landscape analyses, literature reviews, country case-studies, a data triangulation analysis, as well as surveys of experts. Data quality (DQ) was defined as data that are accurate, precise, relevant, complete, and timely enough for the intended purpose (fit-for-purpose), and data use as the degree to which data are actually used for defined purposes, e.g., immunization programme management, performance monitoring, decision-making. The WG outlined roles and responsibilities for immunization and surveillance DQ and use by programme level.The WG found that while DQ is dependent on quality data collection at health facilities, many interventions have targeted national and subnational levels, or have focused on new technologies, rather than the people and enabling environments required for functional information systems. The WG concluded that sustainable improvements in immunization and surveillance DQ and use will require efforts across the health system — governance, people, tools, and processes, including use of data for continuous quality improvement (CQI) — and that the approaches need to be context-specific, country-owned and driven from the frontline up. At the country level, major efforts are needed to: (1) embed monitoring DQ and use alongside monitoring of immunization and surveillance performance, (2) increase workforce capacity and capability for DQ and use, starting at the facility level, (3) improve the accuracy of immunization programme targets (denominators), (4) enhance use of existing data for tailored programme action (e.g., immunization programme planning, management and policy-change), (5) adopt a data-driven CQI approach as part of health system strengthening, (6) strengthen governance around piloting and implementation of new information and communication technology tools, and (7) improve data sharing and knowledge management across areas and organizations for improved transparency and efficiency.Global and regional partners are requested to support countries in adopting relevant recommendations for their setting and to continue strengthening the reporting and monitoring of immunization and VPD surveillance data through processes periodic needs assessment and revision processes. This summary of the WG’s findings and recommendations can support “data-guided” implementation of the new Immunization Agenda 2030.     

Wellness in the Schools: A Lunch Intervention Increases Fruit and Vegetable Consumption

Wellness in the Schools (WITS) is a national non-profit organization partnering with public schools to provide healthy, scratch cooked, less processed meals (called an Alternative Menu), and active recess. This study examined the effects of WITS programming on school lunch consumption, including fruit and vegetable intake, in second and third grade students in New York City public schools serving a high proportion of students from low-income households. The intervention was evaluated with a quasi-experimental, controlled design with 14 elementary schools (7 that had initiated WITS programming in fall 2015 and were designated as intervention schools, and 7 matched Control schools). School lunch consumption was assessed by anonymous observation using the System of Observational Cafeteria Assessment of Foods Eaten (SOCAFE) tool in the fall of 2015 (Time 0, early intervention) and the spring of 2016 (Time 1) and 2017 (Time 2). There were no baseline data. Data were also collected on the types of entrées served in the months of October, January, and April during the two school years of the study. Across time points, and relative to students in the Control schools, students in WITS schools ate more fruits and vegetables (units = cups): Time 0: Control 0.18 vs. WITS 0.28; Time 1: Control 0.25 vs. WITS 0.31; and Time 2: Control 0.19 vs. WITS 0.27; p < 0.001. They also had more fruits and vegetables (cups) on their trays, which included more vegetables from the salad bar. However, students in the WITS schools ate fewer entrées (grain and protein) and drank less milk than students in the Control schools. Compared to the Control schools, WITS schools offered more homestyle entrées and fewer finger foods and sandwich entrees, i.e., less processed food. Students in WITS schools who received the Alternative menu and all of the WITS programming at all data collection time points selected and consumed more fruits and vegetables. Replication studies with randomized designs and true baseline data are needed to confirm these findings and to identify avenues for strengthening the effects of the program on other school lunch components.     

Vaccination program in a resource-limited setting: A case study in the Philippines

ObjectiveImplementing national-level vaccination programs involves long-term investment, which can be a significant financial burden, particularly in resource-limited settings. Although many studies have assessed the economic impacts of providing vaccinations, evidence on the positive and negative implications of human resources for health (HRH) is still lacking. Therefore, this study aims to estimate the HRH impact of introducing pneumococcal conjugate vaccine (PCV) using a model-based economic evaluation.MethodsThis study adapted a Markov model from a prior study that was conducted in the Philippines for assessing the cost-effectiveness of 10-valent and 13-valent PCV compared to no vaccination. The Markov model was used for estimating the number of cases of pneumococcal-related diseases, categorized by policy options. HRH-related parameters were obtained from document reviews and interviews using the quantity, task, and productivity model (QTP model).ResultsThe number of full-time equivalent (FTE) of general practitioners, nurses, and midwives increases significantly if the universal vaccine coverage policy is implemented. A universal coverage of PCV13 - which is considered to be the best value for money compared to other vaccination strategies - requires an additional 380 FTEs for general practitioners, 602 FTEs for nurses, and 205 FTEs for midwives; it can reduce the number of FTEs for medical social workers, paediatricians, infectious disease specialists, neurologists, anaesthesiologists, radiologists, ultrasonologists, medical technologists, radiologic technologists, and pharmacists by 7, 17.9, 9.7, 0.4, 0.1, 0.7, 0.1, 12.3, 2, and 9.7, respectively, when compared to the no vaccination policy.ConclusionThis is the first attempt to estimate the impact of HRH alongside a model-based economic evaluation study, which can be eventually applied to other vaccine studies, especially those which inform resource allocation in developing settings where not only financial resources but also HRH are constrained.     

Influenza vaccination coverage of population and the factors influencing influenza vaccination in mainland China: A meta-analysis

IntroductionThe best way to prevent influenza is receiving vaccination. However, the influenza vaccination coverage in mainland China was low. A meta-analysis was conducted to estimate the vaccination rates of the population and the factors influencing influenza vaccination in mainland China.MethodsA systematic study was conducted on March 18, 2018, using Chinese language databases including China National Knowledge Infrastructure, Chinese Science and Technology Periodical Database, WanFang Database, and English language databases including PubMed, Web of Science, and Cochrane Library. Based on the inclusion and exclusion criteria, the pooled coverage rate and estimated odds ratios (OR) of influencing factors were obtained using data abstraction. Subgroup analysis and meta-regression analysis were also employed to explore the heterogeneity.ResultsThe pooled vaccination coverage rate in 126 included articles was 23.2% (95% confidence interval (CI): 22.8%, 23.7%), and the pooled vaccination rate among the general population was 9.4% (95% CI: 8.0%, 10.9%). The influenza vaccination rate fluctuated from 2005 to 2017. Vaccination rates in 2009–2010 were much higher than other years, pandemic influenza vaccination rate was 37.3% (95% CI: 28.4%, 46.1%) and seasonal influenza vaccination rate was 29.8% (95% CI: 24.6%, 34.9%). In the analysis of influencing factors, those recommended by healthcare workers was the most reported reasons for influenza vaccination with an OR = 5.2 (95% CI: 2.9, 9.4), and following as received influenza vaccination previously, perceived safety of vaccination, perceived effectiveness of vaccination, perceived severity of the disease. Meta-regression analysis indicate that the heterogeneity maybe significantly consistent with the sample size, study population, study region, and vaccination policy.ConclusionCompared with other countries (the United States), vaccination rates were lower in mainland China. There were a few factors influencing the rate, which included vaccination policy, vaccination history and knowledge and attitudes toward influenza and vaccination.     

Evaluation of the effectiveness of maternal immunization against pertussis in Alberta using agent-based modeling: A Canadian immunization research network study

IntroductionThe re-emergence of pertussis has occurred in the past two decades in developed countries. The highest morbidity and mortality is seen among infants. Vaccination in pregnancy is recommended to reduce the pertussis burden in infants.MethodsWe developed and validated an agent-based model to characterize pertussis epidemiology in Alberta. We computed programmatic effectiveness of pertussis vaccination during pregnancy (PVE) in relation to maternal vaccine coverage and pertussis disease reporting thresholds. We estimated the population preventable fraction (PFP) of different levels of maternal vaccine coverage against counterfactual ”no-vaccination” scenario. We modeled the effect of immunological blunting and measured protection through interruption of exposure pathways.ResultsPVE was inversely related to duration of passive immunity from maternal immunization across most simulations. In the scenario of 50% maternal vaccine coverage, PVE was 87% (95% quantiles 82–91%), with PFP of 44% (95% quantiles 41–45%). For monthly age intervals of 0–2, 2–4, 4–6 and 6–12, PVE ranged between 82 and 99%, and PFP ranged between 41 and 49%. At 75% maternal vaccine coverage, PVE and PFP were 90% (95% quantiles 86–92%) and 68% (95% quantiles 65–69%), respectively. At 50% maternal vaccine coverage and 10% blunting, PVE and PFP were 86% (95% quantiles 77–87%) and 43% (95% quantiles 39–44%), respectively, while at 50% blunting, the corresponding values of PVE and PFP were 76% (95% quantiles 70–81%) and 38% (95% quantiles 35–40%). PVE attributable to interruption of exposure pathways was 54–57%.ConclusionsOur model predicts significant reduction in future pertussis cases in infants due to maternal vaccination, with immunological blunting slightly moderating its effectiveness. The model is most sensitive to maternal vaccination coverage. The interruption of exposure pathways plays a role in the reduction of pertussis burden in infants due to maternal immunization. The effect of maternal immunization on population other than infants remains to be elucidated.     

Strengthening vaccination programmes and health systems in the European Union: A framework for action

Vaccination is one of the most cost-effective public health interventions. However, the EU is facing increasing outbreaks of vaccine preventable diseases, with some fatal cases of measles. This paper reviews the main factors influencing vaccination uptake, and assesses measures expected to improve vaccination coverage. Obstacles to vaccination include concerns about vaccine safety and side effects, lack of trust, social norms, exposure to rumours and myths, and access barriers. Responses fall into three broad categories. Regulation, including the introduction of mandatory vaccination, can be justified but it is important to be sure that it is an appropriate solution to the existing problem and does not risk unintended consequences. Facilitation involves ensuring that there is an effective vaccination programme, comprehensive in nature, and reducing the many barriers, in terms of cost, distance, and time, to achieving high levels of uptake, especially for marginalised or vulnerable populations. Information is crucial, but whether in the form of public information campaigns or interactions between health workers and target populations, must be designed very carefully to avoid the risk of backfire. There is no universal solution to achieving high levels of vaccine uptake but rather a range or combinations of options. The choice of which to adopt in each country will depend on a detailed understanding of the problem, including which groups are most affected.     

A global review of national influenza immunization policies: Analysis of the 2014 WHO/UNICEF Joint Reporting Form on immunization

IntroductionThe WHO recommends annual influenza vaccination to prevent influenza illness in high-risk groups. Little is known about national influenza immunization policies globally.Material and MethodsThe 2014 WHO/UNICEF Joint Reporting Form (JRF) on Immunization was adapted to capture data on influenza immunization policies. We combined this dataset with additional JRF information on new vaccine introductions and strength of immunization programmes, as well as publicly available data on country economic status. Data from countries that did not complete the JRF were sought through additional sources. We described data on country influenza immunization policies and used bivariate analyses to identify factors associated with having such policies.ResultsOf 194 WHO Member States, 115 (59%) reported having a national influenza immunization policy in 2014. Among countries with a national policy, programmes target specific WHO-defined risk groups, including pregnant women (42%), young children (28%), adults with chronic illnesses (46%), the elderly (45%), and health care workers (47%). The Americas, Europe, and Western Pacific were the WHO regions that had the highest percentages of countries reporting that they had national influenza immunization policies. Compared to countries without policies, countries with policies were significantly more likely to have the following characteristics: to be high or upper middle income (p < 0.0001); to have introduced birth dose hepatitis B virus vaccine (p < 0.0001), pneumococcal conjugate vaccine (p = 0.032), or human papilloma virus vaccine (p = 0.002); to have achieved global goals for diphtheria-tetanus-pertussis vaccine coverage (p < 0.0001); and to have a functioning National Immunization Technical Advisory Group (p < 0.0001).ConclusionsThe 2014 revision of the JRF permitted a global assessment of national influenza immunization policies. The 59% of countries reporting that they had policies are wealthier, use more new or under-utilized vaccines, and have stronger immunization systems. Addressing disparities in public health resources and strengthening immunization systems may facilitate influenza vaccine introduction and use.     

The 5As: A practical taxonomy for the determinants of vaccine uptake

Suboptimal vaccine uptake in both childhood and adult immunisation programs limits their full potential impact on global health. A recent progress review of the Global Vaccine Action Plan stated that “countries should urgently identify barriers and bottlenecks and implement targeted approaches to increase and sustain coverage”. However, vaccination coverage may be determined by a complex mix of demographic, structural, social and behavioral factors. To develop a practical taxonomy to organise the myriad possible root causes of a gap in vaccination coverage rates, we performed a narrative review of the literature and tested whether all non-socio-demographic determinants of coverage could be organised into 4 dimensions: Access, Affordability, Awareness and Acceptance. Forty-three studies were reviewed, from which we identified 23 primary determinants of vaccination uptake. We identified a fifth domain, Activation, which captured interventions such as SMS reminders which effectively nudge people towards getting vaccinated. The 5As taxonomy captured all identified determinants of vaccine uptake. This intuitive taxonomy has already facilitated mutual understanding of the primary determinants of suboptimal coverage within inter-sectorial working groups, a first step towards them developing targeted and effective solutions.     

Implementation of the Standards for adult immunization practice: A survey of U.S. Health care providers

The revised Standards for Adult Immunization Practice (“Standards”), published in 2014, recommend routine vaccination assessment, strong provider recommendation, vaccine administration or referral, and documentation of vaccines administered into immunization information systems (IIS). We assessed clinician and pharmacist implementation of the Standards in the United States from 2016 to 2018. Participating clinicians (family and internal medicine physicians, obstetricians-gynecologists, specialty physicians, physician assistants, and nurse practitioners) and pharmacists responded using an internet panel survey. Weighted proportion of clinicians and pharmacists reporting full implementation of each component of the Standards were calculated. Adjusted prevalence ratio (APR) estimates of practice characteristics associated with self-reported implementation of the Standards are also presented. Across all medical specialties, the percentages of clinicians and pharmacists implementing the vaccine assessment and recommendation components of the Standards were >80.0%. However, due to low IIS documentation, full implementation of the Standards was low overall, ranging from 30.4% for specialty medicine to 45.8% in family medicine clinicians. The presence of an immunization champion (APR, 1.40 [95% confidence interval {CI}, 1.26 to 1.54]), use of standing orders (APR, 1.41 [95% CI, 1.27 to 1.57]), and use of a patient reminder-recall system (APR, 1.39 [95% CI, 1.26 to 1.54]) were positively associated with adherence to the Standards by clinicians. Similar results were observed for pharmacists.Nonetheless, vaccination improvement strategies, i.e., having standing orders in place, empowering an immunization champion, and using patient recall-reminder systems were underutilized in clinical settings; full implementation of the Standards was inconsistent across all health care provider practices.     

Inequalities in infant vaccination coverage during the COVID-19 pandemic: A population-based study in Peru

ObjectiveTo identify the associated factors and assess the inequalities of full vaccination coverage (FVC) among Peruvian infants aged 12–23 months during the COVID-19 pandemic in a nationally representative sample.MethodsWe carried out a population-based cross-sectional study based on a secondary data analysis using the 2021 Peruvian Demographic Health Survey (DHS) in infants aged 12 to 23 months. The sampling design was probabilistic, multistage, stratified, and independent at both departmental and area of residence levels. FVC was defined according to the WHO definition. We performed generalized linear models (GLM) Poisson family log link function to estimate crude (aPR) and adjusted prevalence ratios (aPR). Also, for inequality assessment, we calculated the concentration curve (CC), concentration index (CI), and Erreygers normalized concentration index (ECI).ResultsWe included 4,189 infants in our analysis. Nationwide, the prevalence of FVC was 66.19% (95% CI: 64.33–68). Being younger, having a mother with no education or primary education, belonging to a large family, having no access to mass media, having had six or fewer ANC visits, and having a mother whose age was under 20 at first delivery were inversely associated with FVC. Meanwhile, living in the Highlands or on the rest of the coast, and living in rural areas were directly associated with FVC. We found a pro-rich inequality in FVC based on wealth-ranked households (CI: 0.0066; ECI: 0.0175).ConclusionFVC has dropped among Peruvian infants aged between 12 and 23 months. There were several factors associated with FVC. It was more concentrated among the better-off infants, although in low magnitude.     

Acceptance of vaccination during pregnancy: experience with 2009 influenza A (H1N1) in the Netherlands

Objectives

In 2009, the Dutch government advised pregnant women to get vaccinated against influenza A (H1N1). A study was set up to gain insight into vaccination coverage and reasons why pregnant women seek vaccination or not.

Methods

We invited 14,529 pregnant women to complete an internet survey on vaccination during pregnancy in general and against 2009 influenza A (H1N1). Differences in background characteristics between unvaccinated and vaccinated women were investigated. Prediction analyses were carried out to determine which survey statement had the greatest impact on vaccination status or intention to get vaccinated during pregnancy.

Results

Of the 2993 included respondents, 63% reported to be vaccinated against 2009 influenza A (H1N1). Vaccination coverage was higher among older birth cohorts, women who had been pregnant before, women with underlying medical conditions, and women who reported no defined ‘life philosophy’. Protection of the child (after birth), the government's advice and possible harmful effects of the vaccine for the unborn child had the greatest predictive value for vaccination status. With regards vaccination during future pregnancies, 39% had a positive intention to obtain vaccination and 45% were neutral. The government's advice was the strongest predictor for intention. Furthermore, women expressed concern over lack of sufficient knowledge about vaccine safety.

Conclusions

A considerable number of pregnant women in the Netherlands reported to be vaccinated against 2009 influenza A (H1N1). The challenge for the government in the future will be to provide pregnant women and health care professionals with sufficient and clear information about disease severity and the benefits and safety of vaccination.     

Efforts to monitor Global progress on individual and community demand for immunization: Development of definitions and indicators for the Global Vaccine Action Plan Strategic Objective 2

The Second Strategic Objective of the Global Vaccine Action Plan, “individuals and communities understand the value of vaccines and demand immunization as both their right and responsibility”, differs from the other five in that it does not focus on supply-side aspects of immunization programs but rather on public demand for vaccines and immunization services. This commentary summarizes the work (literature review, consultations with experts, and with potential users) and findings of the UNICEF/World Health Organization Strategic Objective 2 informal Working Group on Vaccine Demand, which developed a definition for demand and indicators related to Strategic Objective 2. Demand for vaccines and vaccination is a complex concept that is not external to supply systems but rather encompasses the interaction between human behaviors and system structure and dynamics.     

Impact of the COVID-19 pandemic on pediatric and adolescent vaccinations and well child visits in the United States: A database analysis

BackgroundThe COVID-19 pandemic has disrupted healthcare, including immunization practice and well child visit attendance. Maintaining vaccination coverage is important to prevent disease outbreaks and morbidity. We assessed the impact of the COVID-19 pandemic on pediatric and adolescent vaccination administration and well child visit attendance in the United States.MethodsThis cross-sectional study used IBM MarketScan Commercial Database (IMC) with Early View (healthcare claims database) and TriNetX Dataworks Global Network (electronic medical records database) from January 2018–March 2021. Individuals ≤ 18 years of age who were enrolled during the analysis month of interest (IMC with Early View) or had ≥ 1 health encounter at a participating institution (TriNetX Dataworks) were included. We calculated the monthly percent difference between well child visit attendance and vaccine administration rates for 10 recommended pediatric/adolescent vaccines in 2020 and 2021 compared with 2018–2019. Data were stratified by the age groups 0–2 years, 4–6 years, and 9–16 years.ResultsIn IMC with Early View, the average monthly enrollment for children 0–18 years of age was 5.2 million. In TriNetX Dataworks, 12.2 million eligible individuals were included. Well child visits and vaccinations reached the lowest point in April 2020 compared with 2018–2019. Well child visit attendance and vaccine administration rates were inversely related to age, with initial reductions highest for adolescents and lowest for ages 0–2 years. Rates rebounded in June and September 2020 and stabilized to pre-pandemic levels in Fall 2020. Rates dropped below baseline in early 2021 for groups 0–2 years and 4–6 years.ConclusionsWe found substantial disruptions in well child visit attendance and vaccination administration for children and adolescents during the COVID-19 pandemic in 2020 and early 2021. Continued efforts are needed to monitor recovery and catch up to avoid outbreaks and morbidity associated with vaccine-preventable diseases.     

The first national adult immunization summit 2012: Implementing change through action

To address lagging vaccine coverage among adults in the United States, over 150 organizations representing a wide range of immunization partners convened in Atlanta, GA from May 15–16, 2012 for the inaugural National Adult Immunization Summit. The meeting called for solution-oriented discussion toward improving current immunization levels, implementing the 2011 National Vaccine Advisory Committee adult immunization recommendations, and capitalizing on new opportunities to improve coverage. Provisions in the federal health reform law that increase access to preventive services, including immunizations, and the increasing numbers of complementary vaccine providers such as pharmacists, create new opportunities to increase access for immunization services and improve coverage for adults. The Summit organized around five focal areas: empowering providers, quality and performance measures, increasing access and collaboration, educating patients, and informing decision-makers. These focal areas formed the basis of working groups, charged to coordinate efforts by the participating organizations to address gaps in the current immunization system. Summit participants identified priority themes to address as tasks during the coming year, including better communicating the value of immunizations to increase demand for immunizations, creating a central repository of resources for providers, patients, and others interested in improving adult immunization levels, examining performance and quality measures and evaluating means to use such measures to motivate vaccine providers, increasing engagement with employer and employee groups to increase awareness and demand for vaccinations, improving the use of immunization information systems and electronic health reports, decreasing barriers to all vaccine providers including pharmacists and community vaccinators, decreasing the complexity of the adult vaccine schedule where possible, engaging adult immunization champions and leaders in key sectors, including adult healthcare provider groups, and encouraging more integration of immunization services with other preventive services.