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Prevalence of influenza-specific vaccination hesitancy among adults in the United States, 2018
•Two in five adults were hesitant to receive an influenza vaccination.•Hesitancy was negatively associated with vaccination.•Females and non-Hispanic Black adults were more likely to be hesitant.•31% of the non-vaccination among unvaccinated adults is attributable to hesitancy.
The role of vaccine hesitancy on influenza vaccination is not clearly understood. Low influenza vaccination coverage in U.S. adults suggests that a multitude of factors may be responsible for under-vaccination or non-vaccination including vaccine hesitancy. Understanding the role of influenza vaccination hesitancy is important for targeted messaging and intervention to increase influenza vaccine confidence and uptake. The objective of this study was to quantify the prevalence of adult influenza vaccination hesitancy (IVH) and examine association of IVH beliefs with sociodemographic factors and early-season influenza vaccination.
A four-question validated IVH module was included in the 2018 National Internet Flu Survey. Weighted proportions and multivariable logistic regression models were used to identify correlates of IVH beliefs.
Overall, 36.9% of adults were hesitant to receive an influenza vaccination; 18.6% expressed concerns about vaccination side effects; 14.8% personally knew someone with serious side effects; and 35.6% reported that their healthcare provider was not the most trusted source of information about influenza vaccinations. Influenza vaccination ranged from 15.3 to 45.2 percentage points lower among adults self-reporting any of the four IVH beliefs. Being female, age 18–49 years, non-Hispanic Black, having high school or lower education, being employed, and not having primary care medical home were associated with hesitancy.
Among the four IVH beliefs studied, being hesitant to receiving influenza vaccination followed by mistrust of healthcare providers were identified as the most influential hesitancy beliefs. Two in five adults in the United States were hesitant to receive an influenza vaccination, and hesitancy was negatively associated with vaccination. This information may assist with targeted interventions, personalized to the individual, to reduce hesitancy and thus improve influenza vaccination acceptance.
Journal Article
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Underreported influenza mortality in Central and Eastern Europe hinders the extension of seasonal influenza vaccination programs in older adults
Several Central and Eastern European (CEE) countries have low seasonal influenza vaccination coverage of older adults coupled with severe underreporting of influenza-related deaths. Our objective was to project influenza mortality estimates for older adults in six CEE countries, building on high-quality mortality data from an EU-15 country with similar climate, population density, and seasonal influenza vaccination coverage. In addition, we aimed to compare the implications of the reported and projected influenza burden estimates on the economic value of extended influenza vaccination for older adults in an exemplary CEE country, Serbia. Multivariate regression modelling was used to adjust for differences in population health status between countries. Economic implication of underreporting influenza burden was investigated by using the VITALO decision analytic model. Locally reported and projected mortality rates were similar in Czech Republic and Slovenia, whereas projected mortality rates far exceeded locally reported influenza mortality rates in Poland, Hungary, Serbia, and Romania. Based on locally reported mortality rates in Serbia, increasing seasonal influenza vaccination coverage in the 65+ population to average coverage in the EU-27 would prevent 2.86 deaths and would generate 16.52 QALYs at the incremental cost of 2,847,994 EUR annually, which translates to 172,378 EUR/QALY incremental cost-effectiveness ratio (ICER). However, adopting Austrian influenza mortality rates adjusted to higher frailty prevalence in Serbia, increased vaccination coverage would prevent 28.96 deaths and generate 132.77 QALYs at the incremental cost of 2,803,675 EUR annually with an 21,116 EUR/QALY ICER, below Serbian willingness to pay threshold. Accordingly, extension of seasonal influenza vaccination in older adults would be a cost-effective public health intervention in Serbia. Underreporting of adult influenza mortality rates prevent policymakers from understanding the true economic value of influenza vaccination. Our approach is applicable in further countries with low reported influenza mortality rates.
•Underreported influenza mortality with low vaccination coverage in CEE.•Projected influenza mortality estimates in the elderly for 6 CEE countries.•Revised economic value of seasonal influenza vaccination in an exemplary country.•Transferable approach to further countries with underreported influenza mortality.
Journal Article
Seasonal influenza vaccination coverage and the social determinants of influenza vaccination among people over 50 with diabetes in Europe: Analyzing population-based SHARE data for the 2019–2020 and 2021–2022 influenza seasons
Seasonal influenza vaccination coverage data for adults with chronic medical conditions are very scarce. We aimed to investigate the influenza vaccination rates and explore the common social determinants associated with vaccination in Europe across two influenza seasons.
This cross-sectional study used data from the European SHARE survey for the 2019–2020 and 2021–2022 influenza seasons. Participants over 50 diagnosed with diabetes were included, and weighted influenza vaccination rates for both seasons were calculated. Multivariable analyses were used to examine the relationships between vaccination coverage and demographic, physical, social, and healthcare factors over the two seasons.
The weighted seasonal influenza vaccination coverage rate was significantly higher in the 2021–2022 season (54 %) than in the 2019–2020 season (46 %) among people over 50 with diabetes. Factors simultaneously and positively associated with influenza vaccination in both seasons included being aged 65 or older; residing in Western, Northern, or Southern Europe; satisfaction with basic health insurance; having supplementary health insurance; and frequent medical consultations.
Despite the increase, the average European influenza vaccination level remains below the EU target of 75 %. This study fills an important data gap for the ECDC by providing information on influenza vaccination coverage rates among people over 50 with diabetes. The findings highlight the crucial role of a robust social and healthcare system in promoting vaccination. To improve vaccination rates, the ECDC-funded VENICE network should enhance vaccination knowledge, address socioeconomic disparities by strengthening local programs and funding, and collaborate with various stakeholders to develop regional strategies.
•Seasonal influenza vaccination data for adults with chronic conditions are very scarce, as reported by the ECDC.•In Europe, seasonal influenza vaccination coverage rate in the 2021–2022 season was higher than in 2019–2020 for people over 50 with diabetes.•This study addresses an ECDC data gap by reporting vaccination coverage rates among adults over 50 with diabetes.•The findings highlight the crucial role of a robust social and healthcare system in promoting vaccination.
Journal Article
Maternal Tdap and influenza vaccination uptake 2017-2021 in the United States: Implications for maternal RSV vaccine uptake in the future
•Of >1 million births 2017-2021, 55% were born to mothers who had Tdap vaccination.•Maternal Tdap vaccination uptake peaked at gestational age of 27-32 weeks.•Of >750,000 births 2017-2021, 33% were born to mothers with influenza vaccination.•Maternal influenza vaccination uptake correlated with peak influenza months.•Maternal vaccine uptake estimates may improve estimation of future vaccine impact.
Assessment of maternal vaccine coverage is important for understanding and quantifying the impact of currently recommended vaccines as well as modeling the potential impact of future vaccines. However, existing data lack detail regarding uptake according to week of gestational age (wGA). Such granularity is valuable for more accurate estimation of vaccine impact.
To summarize contemporary maternal Tdap vaccination uptake, overall, yearly, and by wGA, and maternal influenza vaccination uptake, overall, by influenza observation year, immunization month, and delivery month, in the US.
Female patients 18-49 years of age with a pregnancy resulting in a live born infant (i.e., delivery) between 2017 and 2021 were selected from the Optum electronic health records (EHRs) database. Recently published gestational age algorithms were utilized to estimate wGA.
Of 1,021,260 deliveries among 886,660 women between 2017-2021, 55.1% had Tdap vaccination during pregnancy; vaccine coverage varied slightly by year (2017: 56.6%; 2018: 55.2%; 2019: 55.2%; 2020: 54.7%; 2021: 52.1%). Most (64.4%) maternal Tdap vaccinations occurred 27-32 wGA; 79.5% occurred during the entire 10-week recommended vaccination window (27-36 wGA). In the evaluation of influenza vaccination uptake (n=798,113 deliveries; 714,841 women), 33.5% of deliveries had influenza vaccination during influenza observation years 2017-2021, most (73.0%) of which occurred during influenza peak activity months (October-January) with approximately one-quarter (27.0%) of vaccinations having occurred during the off-peak months, mostly in September.
In this large contemporary analysis of EHR data, uptake of Tdap vaccination during pregnancy was consistent with previously published estimates; notably, most vaccination occurred early in the recommended 27-36 wGA window. Maternal influenza vaccination uptake largely correlated with peak influenza activity months and not gestational age. These study findings may have important implications for estimating the potential uptake and impact of future maternal vaccines.
Journal Article
Priority allocation of pandemic influenza vaccines in Australia – Recommendations of 3 community juries
Pandemic planning has historically been oriented to respond to an influenza virus, with vaccination strategy being a key focus. As the current COVID-19 pandemic plays out, the Australian government is closely monitoring progress towards development of SARS-CoV2 vaccines as a definitive intervention. However, as in any pandemic, initial supply will likely be exceeded by demand due to limited manufacturing output.
We convened community juries in three Australian locations in 2019 to assess public acceptability and perceived legitimacy of influenza pandemic vaccination distribution strategies. Preparatory work included literature reviews on pandemic vaccine allocation strategies and on vaccine allocation ethics, and simulation modelling studies. We assumed vaccine would be provided to predefined priority groups. Jurors were then asked to recommend one of two strategies for distributing remaining early doses of vaccine: directly vaccinate people at higher risk of adverse outcomes from influenza; or indirectly protect the general population by vaccinating primary school students, who are most likely to spread infection.
Thirty-four participants of diverse backgrounds and ages were recruited through random digit dialling and topic-blinded social media advertising. Juries heard evidence and arguments supporting different vaccine distribution strategies, and questioned expert presenters. All three community juries supported prioritising school children for influenza vaccination (aiming for indirect protection), one by 10–2 majority and two by consensus. Justifications included that indirect protection benefits more people and is likely to be more publicly acceptable.
In the context of an influenza pandemic, informed citizens were not opposed to prioritising groups at higher risks of adverse outcomes, but if resources and epidemiological conditions allow, achieving population benefits should be a strategic priority. These insights may inform future SARS-CoV-2 vaccination strategies.
Journal Article
Seasonal influenza vaccination in middle-income countries: Assessment of immunization practices in Belarus, Morocco, and Thailand
•Seasonal influenza vaccine post-introduction evaluations (IPIEs) were conducted.•Critical implementation issues were highlighted across three middle-income countries.•Health workers have an important dual role in seasonal influenza vaccination.•Pregnant women vaccination should be prioritized and acceptance issues addressed.•The IPIE tool is available to countries for download on the WHO website.
Vaccines for the control of seasonal influenza are recommended by the World Health Organization (WHO) for use in specific risk groups, but their use requires operational considerations that may challenge immunization programs. Several middle-income countries have recently implemented seasonal influenza vaccination. Early program evaluation following vaccine introduction can help ascertain positive lessons learned and areas for improvement.
An influenza vaccine post-introduction evaluation (IPIE) tool was developed jointly by WHO and the U.S. Centers for Disease Control and Prevention to provide a systematic approach to assess influenza vaccine implementation processes. The tool was used in 2017 in three middle-income countries: Belarus, Morocco and Thailand.
Data from the three countries highlighted a number of critical factors: Health workers (HWs) are a key target group, given their roles as key influencers of acceptance by other groups, and for ensuring vaccine delivery and improved coverage. Despite WHO recommendations, pregnant women were not always prioritized and may present unique challenges for acceptance. Target group denominators need to be better defined, and vaccine coverage should be validated with vaccine distribution data, including from the private sector. There is a need for strengthening adverse events reporting and for addressing potential vaccine hesitancy through the establishment of risk communication plans. The assessments led to improvements in the countries’ influenza vaccination programs, including a revision of policies, changes in vaccine management and coverage estimation, enhanced strategies for educating HWs and intensified collaboration between departments involved in implementing seasonal influenza vaccination.
The IPIE tool was found useful for delineating operational strengths and weaknesses of seasonal influenza vaccination programs. HWs emerged as a critical target group to be addressed in follow-up action. Findings from this study can help direct influenza vaccination programs in other countries, as well as contribute to pandemic preparedness efforts. The updated IPIE tool is available on the WHO website http://www.who.int/immunization/research/development/influenza/en/index1.html.
Journal Article
Influenza vaccination coverage among adults with diabetes, United States, 2007–08 through 2017–18 seasons
•Influenza vaccination coverage among adults with diabetes has not changed over the 11 influenza seasons.•Coverage among adults with diabetes ranged from 62.6% to 64.8% in the 2007–08 to 2017–18 seasons.•Coverage was higher among people with diabetes compared with those without diabetes.•Coverage varied by demographic and access-to-care characteristics.
Diabetes is associated with higher risk of hospitalization, morbidity, and mortality from influenza. We assessed influenza vaccination coverage among adults aged ≥ 18 years with diabetes during the 2007–08 through 2017–18 influenza seasons and identified factors independently associated with vaccination during the 2017–18 season.
We analyzed data from the 2007–2018 National Health Interview Surveys, using Kaplan-Meier survival analysis to estimate season-specific influenza vaccination coverage. Multivariate logistic regression was conducted to examine whether diabetes was independently associated with self-reported influenza vaccination in the past 12 months and identify factors independently associated with vaccination among adults with diabetes using the 2017–18 data.
During the 2007–08 through 2017–18 influenza seasons, influenza vaccination coverage among adults aged ≥ 18 years with diabetes ranged from 62.6% to 64.8%. In the 2017–18 influenza season, coverage was significantly higher among adults with diabetes (64.8%) compared with those without diabetes (43.9%). Having diabetes was independently associated with an increased prevalence of vaccination after controlling for other factors. Among adults with diabetes, living at or above poverty level, having more physician contacts, having usual place for health care, and being unemployed were independently associated with increased prevalence of vaccination; being 18–64 years and non-Hispanic black were independently associated with decreased prevalence of vaccination.
Despite specific recommendations for influenza vaccination among people with diabetes, more than one-third of adults with diabetes are unvaccinated. Targeted efforts are needed to increase influenza vaccination coverage among adults with diabetes.
Journal Article
Agreement among sources of adult influenza vaccination in the age of immunization information systems
Many vaccination studies rely on self-reported vaccination status, with its inherent biases. Accuracy of influenza vaccination self-report has been evaluated periodically, typically using the medical record as the gold standard. The burgeoning of electronic medical records (EMRs) and immunization information systems (IISs) and the rise of adult vaccine administration in community pharmacies suggest the need for a reevaluation of self-reported vaccination status.
Vaccination data from self-report, the state IIS, the health system EMR and other sources were compared for participants in outpatient and inpatient influenza vaccine effectiveness studies for four seasons (2016–2017 to 2019–2020). Agreement among the sources was calculated along with sensitivity and specificity. Tests for trend assessed changes in completeness of the Pennsylvania - Statewide IIS (PA-SIIS) data over time.
With self-report as the gold standard, agreement with the local EMR, PA-SIIS, and all sources was 62%, 77% and 85%, respectively. Sensitivity of the EMR was 42% (95% CI = 41, 43) and specificity was 91% (90, 92). With PA-SIIS-as the gold standard, agreement with the local EMR and all sources was 77% and 78%, respectively. Sensitivity of all sources combined was 96% (95, 97) and specificity was (63% (62, 64). Capture of influenza vaccinations in the IIS has not consistently improved over time, with a significant increase among children (P = 0.001), no change among working-age adults and a decrease among older adults (P = 0.004). However, PA-SIIS provided the largest percentage of verified vaccines (69.3%) compared with EMR (43.3%) and other sources (12.4%).
Both self-report and PA-SIIS are good estimates of actual vaccine uptake. When high accuracy data are required, such as for vaccine effectiveness studies, triangulation using multiple sources should be conducted.
Journal Article