Understanding COVID-19 vaccine demand and hesitancy: A nationwide online survey in China

BackgroundThis study attempts to understand coronavirus disease 2019 (COVID-19) vaccine demand and hesitancy by assessing the public’s vaccination intention and willingness-to-pay (WTP). Confidence in COVID-19 vaccines produced in China and preference for domestically-made or foreign-made vaccines was also investigated.MethodsA nationwide cross-sectional, self-administered online survey was conducted on 1–19 May 2020. The health belief model (HBM) was used as a theoretical framework for understanding COVID-19 vaccination intent and WTP.ResultsA total of 3,541 complete responses were received. The majority reported a probably yes intent (54.6%), followed by a definite yes intent (28.7%). The perception that vaccination decreases the chances of getting COVID-19 under the perceived benefit construct (OR = 3.14, 95% CI 2.05–4.83) and not being concerned about the efficacy of new COVID-19 vaccines under the perceived barriers construct (OR = 1.65, 95% CI 1.31–2.09) were found to have the highest significant odds of a definite intention to take the COVID-19 vaccine. The median (interquartile range [IQR]) of WTP for COVID-19 vaccine was CNY¥200/US$28 (IQR CNY¥100–500/USD$14–72). The highest marginal WTP for the vaccine was influenced by socio-economic factors. The majority were confident (48.7%) and completely confident (46.1%) in domestically-made COVID-19 vaccine. 64.2% reported a preference for a domestically-made over foreign-made COVID-19 vaccine.ConclusionsThe findings demonstrate the utility of HBM constructs in understanding COVID-19 vaccination intent and WTP. It is important to improve health promotion and reduce the barriers to COVID-19 vaccination.     

Focus: Health Equity: COVID-19 Healthcare Inequity: Lessons Learned from Annual Influenza Vaccination Rates to Mitigate COVID-19 Vaccine Disparities

The COVID-19 pandemic has infected 33 million Americans and resulted in more than 600,000 deaths as of late Spring 2021. Black, Indigenous, and Latinx (BIL) people are disproportionately infected, hospitalized, and dying. Effective vaccines were rapidly developed and have been widely available in the United States since their initial rollout in late 2020-early 2021 but vaccination rates in BIL communities have remained low compared with non-BIL communities. Limited access to the vaccine, lack of customized information, and mistrust of the medical system, all contribute to vaccine hesitancy and low vaccination rates. Regrettably, COVID-19 is not the only vaccine-preventable illness with racial/ethnic inequities. Similar inequities are seen with the seasonal influenza vaccine. We review the racial/ethnic health disparities in COVID-19 illness and vaccination rates and what inequities contribute to these disparities. We use evidence from the seasonal influenza vaccination efforts to inform potential strategies to attenuate these inequities. The development of effective and sustainable strategies to improve vaccination rates and reduce factors that result in health inequities is essential in managing current and future pandemics and promoting improved health for all communities.     

Left–Right-Position,party affiliation and regional differences explain low COVID-19 vaccination rates in Germany

Established vaccine hesitancy measurement instruments, such as the Vaccine Hesitancy Determinants Matrix, are not sufficiently equipped to adequately and consistently measure political and ideological attitudes. Focusing on Germany, which is a particularly interesting case since it witnessed the establishment of the by far most well-organized and sustained ‘anti-Covid’ movement in Europe, this quantitative study explores the impact of political ideology and partisanship on the degree of vaccine hesitancy based on four surveys (February—October 2021) among more than 30,000 individuals. We demonstrate that party affiliation, political ideology and region of residence all impact vaccine hesitancy. In fact, they turn out to have a greater impact than two factors often analysed with respect to vaccine hesitancy: gender and educational background. Further interaction models show that the effect of political ideology on vaccine hesitancy is moderated by age, gender and region of residency. For instance, while the more rightwing a young individual is, the more hesitant they are towards SARS-CoV-2 vaccination—for older individuals, this is not the case. Our findings are relevant for future investigators measuring vaccine hesitancy and policy makers contemplating the differential impact of complex public health interventions: as the impact of political and ideological attitudes on vaccine hesitancy are not adequately captured by established vaccine hesitancy measurement instruments, we recommend its modification to include a clear and harmonised definition of the political-ideological dimension of vaccine hesitancy together with pre-validated measurement items that improve future studies. In addition, we reason that vaccine hesitancy, while being an outcome of complex socio-political factors, is in itself an indicator for societal cohesion and anomie, the degree of which is associated with trust in (health) policy makers, (public) health authorities, health service providers, etc. Therefore, we further recommend that vaccine hesitancy questions should be integrated in pertinent national surveys.     

Focus: Vaccines: COVID-19, Vaccination,and Conspiracies: A Micro-Level Qualitative Study in Islamabad,Pakistan

Although vaccination is the only hope to fight against COVID-19, existing vaccine hesitancy is a thought-provoking phenomenon. Significantly, vaccine hesitancy is worsening the situation in Pakistan, leading to an increased number of COVID cases. In this context, this study aims to examine people’s perceptions and attitudes towards vaccination. Here the focus was on determining the factors causing disease hesitancy among the masses. The researchers randomly selected a sample of n=17 individuals and gathered data by using telephone interviews and assessed data by using the Interpretive Phenomenological Analysis (IPA) approach. Results revealed that the increased vaccine hesitancy is due to misinformation, conspiracies, myths, and rumors about the side effects of the vaccination. It was also notable that the participants indicated digital media as the primary source of information, showing a potential relationship between social media and misinformation. Also, an intense uncertainty about the healthcare system in Pakistan is hindering the efforts to sustain herd immunity. Thus, due to several myths, rumors, and distrust of the healthcare system, vaccine hesitancy is halting the country’s ability to overcome the COVID-19 outbreak. Misinformation is vigorously circulating due to ease of access to different communication platforms, instilling fear of presumed side effects. Hence, the researchers suggest some practical considerations for the government, healthcare workers, and media platforms to counteract the misinformation and increase vaccine acceptance among the masses.     

Ethnic inequalities in COVID-19 vaccine uptake and comparison to seasonal influenza vaccine uptake in Greater Manchester,UK: A cohort study

BackgroundCOVID-19 vaccine uptake is lower amongst most minority ethnic groups compared to the White British group in England, despite higher COVID-19 mortality rates. Here, we add to existing evidence by estimating inequalities for 16 minority ethnic groups, examining ethnic inequalities within population subgroups, and comparing the magnitudes of ethnic inequalities in COVID-19 vaccine uptake to those for routine seasonal influenza vaccine uptake.Methods and findingsWe conducted a retrospective cohort study using the Greater Manchester Care Record, which contains de-identified electronic health record data for the population of Greater Manchester, England. We used Cox proportional hazards models to estimate ethnic inequalities in time to COVID-19 vaccination amongst people eligible for vaccination on health or age (50+ years) criteria between 1 December 2020 and 18 April 2021 (138 days of follow-up). We included vaccination with any approved COVID-19 vaccine, and analysed first-dose vaccination only. We compared inequalities between COVID-19 and influenza vaccine uptake adjusting by age group and clinical risk, and used subgroup analysis to identify populations where inequalities were widest. The majority of individuals (871,231; 79.24%) were White British. The largest minority ethnic groups were Pakistani (50,268; 4.75%), ‘other White background’ (43,195; 3.93%), ‘other ethnic group’ (34,568; 3.14%), and Black African (18,802; 1.71%). In total, 83.64% (919,636/1,099,503) of eligible individuals received a COVID-19 vaccine. Uptake was lower compared to the White British group for 15 of 16 minority ethnic groups, with particularly wide inequalities amongst the groups ‘other Black background’ (hazard ratio [HR] 0.42, 95% CI 0.40 to 0.44), Black African (HR 0.43, 95% CI 0.42 to 0.44), Arab (HR 0.43, 95% CI 0.40 to 0.48), and Black Caribbean (HR 0.43, 95% CI 0.42 to 0.45). In total, 55.71% (419,314/752,715) of eligible individuals took up influenza vaccination. Compared to the White British group, inequalities in influenza vaccine uptake were widest amongst the groups ‘White and Black Caribbean’ (HR 0.63, 95% CI 0.58 to 0.68) and ‘White and Black African’ (HR 0.67, 95% CI 0.63 to 0.72). In contrast, uptake was slightly higher than the White British group amongst the groups ‘other ethnic group’ (HR 1.11, 95% CI 1.09 to 1.12) and Bangladeshi (HR 1.08, 95% CI 1.05 to 1.11). Overall, ethnic inequalities in vaccine uptake were wider for COVID-19 than influenza vaccination for 15 of 16 minority ethnic groups. COVID-19 vaccine uptake inequalities also existed amongst individuals who previously took up influenza vaccination. Ethnic inequalities in COVID-19 vaccine uptake were concentrated amongst older and extremely clinically vulnerable adults, and the most income-deprived. A limitation of this study is the focus on uptake of the first dose of COVID-19 vaccination, rather than full COVID-19 vaccination.ConclusionsEthnic inequalities in COVID-19 vaccine uptake exceeded those for influenza vaccine uptake, existed amongst those recently vaccinated against influenza, and were widest amongst those with greatest COVID-19 risk. This suggests the COVID-19 vaccination programme has created additional and different inequalities beyond pre-existing health inequalities. We suggest that further research and policy action is needed to understand and remove barriers to vaccine uptake, and to build trust and confidence amongst minority ethnic communities.

Ruth Elizabeth Watkinson and colleagues estimate inequalities in Covid-19 vaccine uptake for 16 minority ethnic groups and compare them to those in routine seasonal Influenza vaccine uptake.     

Why we must fight ignorance about COVID-19 vaccines and menstrual cycles

The COVID-19 pandemic has revealed a critical gap in female health science, fueling anxiety, polarized views, and vaccine hesitancy. Although menstrual cycles feel like a niche topic for some, efforts to augment knowledge on the ‘fifth vital sign’ experienced by more than 300 million people on any given day worldwide are crucial to promote gender equity in health.     

Predictors of the uptake of A (H1N1) influenza vaccine: findings from a population-based longitudinal study in Tokyo

Background

Overall pandemic A (H1N1) influenza vaccination rates remain low across all nations, including Japan. To increase the rates, it is important to understand the motives and barriers for the acceptance of the vaccine. We conducted this study to determine potential predictors of the uptake of A (H1N1) influenza vaccine in a cohort of Japanese general population.

Methodology/Principal Findings

By using self-administered questionnaires, this population-based longitudinal study was conducted from October 2009 to April 2010 among 428 adults aged 18–65 years randomly selected from each household residing in four wards and one city in Tokyo. Multiple logistic regression analyses were performed. Of total, 38.1% of participants received seasonal influenza vaccine during the preceding season, 57.0% had willingness to accept A (H1N1) influenza vaccine at baseline, and 12.1% had received A (H1N1) influenza vaccine by the time of follow-up. After adjustment for potential confounding variables, people who had been vaccinated were significantly more likely to be living with an underlying disease (p = 0.001), to perceive high susceptibility to influenza (p = 0.03), to have willingness to pay even if the vaccine costs ≥ US$44 (p = 0.04), to have received seasonal influenza vaccine during the preceding season (p<0.001), and to have willingness to accept A (H1N1) influenza vaccine at baseline (p<0.001) compared to those who had not been vaccinated.

Conclusions/Significance

While studies have reported high rates of willingness to receive A (H1N1) influenza vaccine, these rates may not transpire in the actual practices. The uptake of the vaccine may be determined by several potential factors such as perceived susceptibility to influenza and sensitivity to vaccination cost in general population.     

Factors associated with the unwillingness of Jordanians,Palestinians and Syrians to be vaccinated against COVID-19

BackgroundThe COVID-19 pandemic is expected to continue to inflect immense burdens of morbidity and mortality, not to mention the sever disruption of societies and economies worldwide. One of the major challenges to managing COVID-19 pandemic is the negative attitudes towards vaccines and the uncertainty or unwillingness to receive vaccinations. We evaluated the predictors and factors behind the negative attitudes towards COVID-19 vaccines in 3 countries in the Middle East.MethodsA cross-sectional, self-administered survey was conducted between the 1^st and the 25^th of December, 2020. Representative sample of 8619 adults residing in Jordan, West Bank, and Syria, completed the survey via the Web or via telephone interview. The survey intended to assess intent to be vaccinated against COVID-19 and to identify predictors of and reasons among participants unwilling/hesitant to get vaccinated.ResultsThe total of the 8619 participants included in this study were the ones who answered the question on the intent to be vaccinated. Overall, 32.2% of participants (n = 2772) intended to be vaccinated, 41.6% (n = 3589) didn’t intend to get vaccinated, and 26.2% (n = 2258) were not sure. The main factors associated with the willingness to take the vaccine (yes responses) included females, 18–35 years old, Syrians and Jordanians, a large family size, and having received a flu vaccine last year. Reasons for vaccine hesitancy included the lack of rigorous evaluation of the vaccine by the FDA and the possible long-term health risks associated with the vaccines (the wait-and-see approach).ConclusionThis survey, conducted in December when the number of cases and deaths per day due to COVID-19 were at or near peak levels of the initial surge in the three regions under investigation. The survey revealed that most of survey’s participants (67.8%) were unwilling/hesitant to get vaccinated against COVID-19 with the lack of trust in the approval process of the vaccine being the main concern; the two main characteristics of those participants were more than 35 years old and participants holding a Bachelor’s degree or higher. Targeted and multi-pronged efforts will be needed to increase acceptance of COVID-19 vaccine in Jordan, West Bank and Syria.     

Seasonal Influenza Vaccination for Children in Thailand: A Cost-Effectiveness Analysis

Background

Seasonal influenza is a major cause of mortality worldwide. Routine immunization of children has the potential to reduce this mortality through both direct and indirect protection, but has not been adopted by any low- or middle-income countries. We developed a framework to evaluate the cost-effectiveness of influenza vaccination policies in developing countries and used it to consider annual vaccination of school- and preschool-aged children with either trivalent inactivated influenza vaccine (TIV) or trivalent live-attenuated influenza vaccine (LAIV) in Thailand. We also compared these approaches with a policy of expanding TIV coverage in the elderly.

Methods and Findings

We developed an age-structured model to evaluate the cost-effectiveness of eight vaccination policies parameterized using country-level data from Thailand. For policies using LAIV, we considered five different age groups of children to vaccinate. We adopted a Bayesian evidence-synthesis framework, expressing uncertainty in parameters through probability distributions derived by fitting the model to prospectively collected laboratory-confirmed influenza data from 2005-2009, by meta-analysis of clinical trial data, and by using prior probability distributions derived from literature review and elicitation of expert opinion. We performed sensitivity analyses using alternative assumptions about prior immunity, contact patterns between age groups, the proportion of infections that are symptomatic, cost per unit vaccine, and vaccine effectiveness. Vaccination of children with LAIV was found to be highly cost-effective, with incremental cost-effectiveness ratios between about 2,000 and 5,000 international dollars per disability-adjusted life year averted, and was consistently preferred to TIV-based policies. These findings were robust to extensive sensitivity analyses. The optimal age group to vaccinate with LAIV, however, was sensitive both to the willingness to pay for health benefits and to assumptions about contact patterns between age groups.

Conclusions

Vaccinating school-aged children with LAIV is likely to be cost-effective in Thailand in the short term, though the long-term consequences of such a policy cannot be reliably predicted given current knowledge of influenza epidemiology and immunology. Our work provides a coherent framework that can be used for similar analyses in other low- and middle-income countries.     

Focus: Vaccines: Embracing the Diversity of Latinx Communities to Promote Vaccinations

While vaccine hesitancy is well documented in the literature among the Latinx community, little attention or effort is given to the nuances among the members of individual communities, such as country of origin, immigration status, generational status, primary language, race, age, sex, gender, or rural residence and how these complexities affect vaccine messaging and uptake. We have evidence that this heterogeneity causes differences in access to healthcare, attitudes towards vaccines, and degree of health disparities. In this review we will describe their impact on vaccination rates in the Latinx community, highlighting missed opportunities for public health outreach, and how targeted messaging could improve vaccine uptake.     

Mass vaccination for the 2009 H1N1 pandemic: approaches, challenges, and recommendations

The 2009 H1N1 pandemic stimulated a nationwide response that included a mass vaccination effort coordinated at the federal, state, and local levels. This article examines a sampling of state and local efforts during the pandemic in order to better prepare for future public health emergencies involving mass distribution, dispensing, and administration of medical countermeasures. In this analysis, the authors interviewed national, state, and local leaders to gain a better understanding of the accomplishments and challenges of H1N1 vaccination programs during the 2009-10 influenza season. State and local health departments distributed and administered H1N1 vaccine using a combination of public and private efforts. Challenges encountered during the vaccination campaign included the supply of and demand for vaccine, prioritization strategies, and local logistics. To improve the response capabilities to deal with infectious disease emergencies, the authors recommend investing in technologies that will assure a more timely availability of the needed quantities of vaccine, developing local public health capacity and relationships with healthcare providers, and enhancing federal support of state and local activities. The authors support in principle the CDC recommendation to vaccinate annually all Americans over 6 months of age against seasonal influenza to establish a standard of practice on which to expand the ability to vaccinate during a pandemic. However, expanding seasonal influenza vaccination efforts will be an expensive and long-term investment that will need to be weighed against anticipated benefits and other public health needs. Such investments in public health infrastructure could be important for building capacity and practice for distributing, dispensing, and administering countermeasures in response to a future pandemic or biological weapons attack.     

Gauging U.S. Emergency Medical Services Workers' Willingness to Respond to Pandemic Influenza Using a Threat- and Efficacy-Based Assessment Framework

Background

Emergency Medical Services workers'' willingness to report to duty in an influenza pandemic is essential to healthcare system surge amidst a global threat. Application of Witte''s Extended Parallel Process Model (EPPM) has shown utility for revealing influences of perceived threat and efficacy on non-EMS public health providers'' willingness to respond in an influenza pandemic. We thus propose using an EPPM-informed assessment of EMS workers'' perspectives toward fulfilling their influenza pandemic response roles.

Methodology/Principal Findings

We administered an EPPM-informed snapshot survey about attitudes and beliefs toward pandemic influenza response, to a nationally representative, stratified random sample of 1,537 U.S. EMS workers from May–June 2009 (overall response rate: 49%). Of the 586 respondents who met inclusion criteria (currently active EMS providers in primarily EMS response roles), 12% indicated they would not voluntarily report to duty in a pandemic influenza emergency if asked, 7% if required. A majority (52%) indicated their unwillingness to report to work if risk of disease transmission to family existed. Confidence in personal safety at work (OR = 3.3) and a high threat/high efficacy (“concerned and confident”) EPPM profile (OR = 4.7) distinguished those who were more likely to voluntarily report to duty. Although 96% of EMS workers indicated that they would probably or definitely report to work if they were guaranteed a pandemic influenza vaccine, only 59% had received an influenza immunization in the preceding 12 months.

Conclusions/Significance

EMS workers'' response willingness gaps pose a substantial challenge to prehospital surge capacity in an influenza pandemic. “Concerned and confident” EMS workers are more than four times as likely to fulfill pandemic influenza response expectations. Confidence in workplace safety is a positively influential modifier of their response willingness. These findings can inform insights into interventions for enhancing EMS workers'' willingness to respond in the face of a global infectious disease threat.     

Predictors of healthcare workers' intention to vaccinate against COVID-19: A cross sectional study from Saudi Arabia

BackgroundVaccination is considered the best way to prevent the spread of COVID-19 and to prevent the complications of the disease. Nevertheless, no awareness campaigns were conducted in Saudi Arabia until March 1, 2021, when the Vaxzevria, or ChAdOx1 nCoV-19 (AZD1222), vaccine became available.ObjectivesThis study aims to determine the factors that can predict healthcare workers’ acceptance of the COVID-19 vaccine.MethodsA cross-sectional study was conducted from July to September 2021, in our university tertiary hospital (King Saud University Medical City [KSUMC]), Riyadh, Saudi Arabia. The study targeted potential participants among healthcare workers at KSUMC. We assessed healthcare workers’ perceptions and beliefs about the COVID-19 vaccine via a questionnaire that was distributed via social media applications such as WhatsApp, Twitter, and Google. Participants were informed about the questionnaire before they filled it out, and they were asked to respond to three screening questions before beginning the main questionnaire. These screening questions ensured that the participants met the inclusion criteria. Included participants were over the age of 18, agreed to answer the questions, and were residents of Saudi Arabia. The participants filled out the self-administered questionnaire.ResultsA total of 529 participants completed the questionnaires. All participants were vaccinated, 68% were female, 55% were married, 35% had been working for less than five years, and 65% had a bachelor’s degree. More than half of participants had not previously been infected with COVID-19, and most did not interact with COVID-19 patients. More convenient access to the vaccine increased the odds ratio of participant vaccination by 0.39. An increase in the number of vaccinated friends and family members increased the odds ratio of participant vaccination by 0.30. However, COVID- 19 vaccination mandates decreased the odds ratio of participant vaccination by 0.27. The fitted linear regression model explained 32% of the variation observed in the dependent variable, acceptance of the COVID-19 vaccine, and the adjusted R squared was 0.32. The fitted regression model was statistically significant at a 95% confidence interval; the p-value was 0.00001.ConclusionIn Saudi Arabia, there is an immense need to increase uptake of the COVID-19 vaccine. This requires encouraging more positive beliefs and attitudes regarding vaccination in general and the COVID-19 vaccine in particular.     

Influenza vaccination in the elderly: 1. Determinants of acceptance.

In the autumn of 1982 routine annual influenza vaccination was offered, by reminder letters and follow-up telephone calls, to 273 independent elderly individuals registered at a community health clinic in Hamilton, Ont. The demographic and geographic characteristics and the health beliefs of those who either accepted or did not accept the vaccine were compared. Among those who received reminder letters there were no significant differences in the rates of vaccine acceptance according to age, sex, household composition or ease of access to the clinic. The patients who reported having previously experienced side effects from the vaccine and perceived a lack of efficacy of the vaccine were more likely not to accept it this time. Both a lack of effort by health care providers (to promote vaccination) and patient behaviour appeared to contribute to pre-existing low levels of influenza vaccination coverage. Although physicians'' efforts to inform patients about the vaccination clinics resulted in a tripling of the overall rate of acceptance of the vaccine, there remained a "hard core" of almost half the patients who were unwilling to receive the vaccine, apparently because they perceived its risks to outweigh its benefits.     

Attitudes toward COVID-19 vaccines in Chinese college students

Background: Vaccination is an important preventative measure against the coronavirus disease 19 (COVID-19) pandemic. To implement vaccination and immunization programs effectively, it is essential to investigate public attitudes toward COVID-19 vaccines. This study examined the attitudes of Chinese college students toward COVID-19 vaccines and their associated factors. Methods: A cross-sectional study was conducted in college students nationwide from December 27, 2020 to January 18, 2021. Attitudes toward COVID-19 vaccines and acceptance of future vaccination programs were assessed. Results: Totally, 2,881 college students participated in this survey; of them, 76.3% (95% CI: 74.8% - 77.9%) were willing to accept a COVID-19 vaccine in the future. Multiple logistic analysis revealed that students living in urban (OR=1.409, 95% CI: 1.152 - 1.724, p=0.001) and those studying health-related courses (OR=1.581, 95% CI: 1.291 - 1.935, p<0.001) were more likely to have a positive attitude toward COVID-19 vaccines. In addition, those who were worried about being infected with COVID-19 (very much vs no, OR=1.690, 95% CI: 1.212-2.356, p=0.002), heard previously about COVID-19 vaccines (OR=1.659, 95% CI: 1.268-2.170, p<0.001), believed that vaccines are safe (Yes vs No, OR=3.570, 95% CI: 1.825-6.980), thought that vaccines can protect people from being infected with COVID-19 (Yes vs No, OR=1.957, 95% CI: 1.286-2.979, p=0.002), and had encouraged their family and friends to have a vaccine (Yes vs No, OR=17.745, 95% CI: 12.271-25.660, p<0.001) had higher acceptance of COVID-19 vaccination. Conclusions: A high rate of acceptance of COVID-19 vaccines was found among Chinese college students. However, vaccine uptake may be reduced by concerns about vaccine safety and efficacy. Alleviating these concerns and enhancing public confidence in vaccines are crucial for future immunization programs against the COVID-19 pandemic.     

Uptake of infant and preschool immunisations in Scotland and England during the COVID-19 pandemic: An observational study of routinely collected data

BackgroundIn 2020, the SARS-CoV-2 (COVID-19) pandemic and lockdown control measures threatened to disrupt routine childhood immunisation programmes with early reports suggesting uptake would fall. In response, public health bodies in Scotland and England collected national data for childhood immunisations on a weekly or monthly basis to allow for rapid analysis of trends. The aim of this study was to use these data to assess the impact of different phases of the pandemic on infant and preschool immunisation uptake rates.Methods and findingsWe conducted an observational study using routinely collected data for the year prior to the pandemic (2019) and immediately before (22 January to March 2020), during (23 March to 26 July), and after (27 July to 4 October) the first UK “lockdown”. Data were obtained for Scotland from the Public Health Scotland “COVID19 wider impacts on the health care system” dashboard and for England from ImmForm.Five vaccinations delivered at different ages were evaluated; 3 doses of “6-in-1” diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, and hepatitis B vaccine (DTaP/IPV/Hib/HepB) and 2 doses of measles, mumps, and rubella (MMR) vaccine. This represented 439,754 invitations to be vaccinated in Scotland and 4.1 million for England. Uptake during the 2020 periods was compared to the previous year (2019) using binary logistic regression analysis. For Scotland, uptake within 4 weeks of a child becoming eligible by age was analysed along with geographical region and indices of deprivation. For Scotland and England, we assessed whether immunisations were up-to-date at approximately 6 months (all doses 6-in-1) and 16 to 18 months (first MMR) of age.We found that uptake within 4 weeks of eligibility in Scotland for all the 5 vaccines was higher during lockdown than in 2019. Differences ranged from 1.3% for first dose 6-in-1 vaccine (95.3 versus 94%, odds ratio [OR] compared to 2019 1.28, 95% confidence intervals [CIs] 1.18 to 1.39) to 14.3% for second MMR dose (66.1 versus 51.8%, OR compared to 2019 1.8, 95% CI 1.74 to 1.87). Significant increases in uptake were seen across all deprivation levels.In England, fewer children due to receive their immunisations during the lockdown period were up to date at 6 months (6-in-1) or 18 months (first dose MMR). The fall in percentage uptake ranged from 0.5% for first 6-in-1 (95.8 versus 96.3%, OR compared to 2019 0.89, 95% CI 0.86– to 0.91) to 2.1% for third 6-in-1 (86.6 versus 88.7%, OR compared to 2019 0.82, 95% CI 0.81 to 0.83).The use of routinely collected data used in this study was a limiting factor as detailed information on potential confounding factors were not available and we were unable to eliminate the possibility of seasonal trends in immunisation uptake.ConclusionsIn this study, we observed that the national lockdown in Scotland was associated with an increase in timely childhood immunisation uptake; however, in England, uptake fell slightly. Reasons for the improved uptake in Scotland may include active measures taken to promote immunisation at local and national levels during this period and should be explored further. Promoting immunisation uptake and addressing potential vaccine hesitancy is particularly important given the ongoing pandemic and COVID-19 vaccination campaigns.

Fiona McQuaid and colleagues assess the uptake of infant and pre-school immunisations in Scotland and England during the COVID-19 pandemic.     

Focus: Vaccines: Distorted Human Decision-Making as a Critical Aspect of Pandemic Planning and Preparedness

The United States continues to experience lower than expected vaccination rates against COVID-19 due to a variety of barriers such as lack of trust, lack of planning, cultural perspectives and issues, suboptimal communication, and political/economic conflicts of interest. In this paper issues of human behavior and decision-making are highlighted as integral to understanding the generally poor US response to the SARS-CoV-2 pandemic. In particular, the US pandemic response was significantly distorted through a combination of cultural and human behavior issues related to conflicting leadership, cultural individualism, the prevalent idea of the democratization of expertise, and a false epistemological lens for decision-making. Including experts from multiple disciplines reveals how to address the human behavioral side of pandemic planning and operations to increase vaccine coverage rates. Including content experts from psychology and the social sciences allows the explicit recognition and preparation for distorted human behavior in planning for future pandemic response.     

Challenges and practices arising during public health emergencies: A qualitative survey on ethics committees

The particular dynamics of public health emergencies urge scientists and Ethics Committee (EC) members to change and adapt their operating procedures to function effectively. Despite having previous pandemic experiences, ethics committees were unprepared to adapt to COVID-19 pandemic challenges. This survey aims to learn and thoroughly discuss the most salient issues for ECs during the COVID-19 pandemic. The results indicate that the main problems faced by ECs were lack of/insufficient regulations, lack of data/experience/knowledge, sloppy review, poor research design, and poor adaptation to quarantine measures. Coping with factors that threaten the autonomy and independence of ECs, the ethical dilemma regarding maximizing common good versus protecting the rights and well-being of study participants, comprehending the change in the context of vulnerable populations, and redefining the role of ECs to strengthen trust in science and vaccine confidence were outstanding issues.     

Assessment of Local Public Health Workers' Willingness to Respond to Pandemic Influenza through Application of the Extended Parallel Process Model

Background

Local public health agencies play a central role in response to an influenza pandemic, and understanding the willingness of their employees to report to work is therefore a critically relevant concern for pandemic influenza planning efforts. Witte''s Extended Parallel Process Model (EPPM) has been found useful for understanding adaptive behavior in the face of unknown risk, and thus offers a framework for examining scenario-specific willingness to respond among local public health workers. We thus aim to use the EPPM as a lens for examining the influences of perceived threat and efficacy on local public health workers'' response willingness to pandemic influenza.

Methodology/Principal Findings

We administered an online, EPPM-based survey about attitudes/beliefs toward emergency response (Johns Hopkins∼Public Health Infrastructure Response Survey Tool), to local public health employees in three states between November 2006 – December 2007. A total of 1835 responses were collected for an overall response rate of 83%. With some regional variation, overall 16% of the workers in 2006-7 were not willing to “respond to a pandemic flu emergency regardless of its severity”. Local health department employees with a perception of high threat and high efficacy – i.e., those fitting a ‘concerned and confident’ profile in the EPPM analysis – had the highest declared rates of willingness to respond to an influenza pandemic if required by their agency, which was 31.7 times higher than those fitting a ‘low threat/low efficacy’ EPPM profile.

Conclusions/Significance

In the context of pandemic influenza planning, the EPPM provides a useful framework to inform nuanced understanding of baseline levels of – and gaps in – local public health workers'' response willingness. Within local health departments, ‘concerned and confident’ employees are most likely to be willing to respond. This finding may allow public health agencies to design, implement, and evaluate training programs focused on emergency response attitudes in health departments.