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To evaluate the impact of a multi-component intervention package of maternal immunization uptake in obstetric care clinics.In a multi-level, cluster- and individually-randomized controlled trial we implemented an evidence-based intervention that targeted practice-, provider- and patient-level barriers to vaccine uptake. Obstetric practices were randomized to receive the practice and provider-level interventions or continue their normal standard of care. We enrolled pregnant women at practices in Georgia and Colorado and randomized women into patient-level intervention and control groups, resulting in four study arms. The primary outcomes were receipt of the influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccines during pregnancy. A sample size of 550 women per arm (2200 total) was planned and enrolled to compare the intervention between the four study arms.Between June 2017 and July 2018, 4907 women were screened and 2200 women were randomized, 550 to each of the four study arms. We were unable to follow-up with 108 women, for a final sample size of 2092. Sample characteristics and sample size were similar among study arms. There was no significant increase in Tdap or influenza vaccine uptake overall. Among women who had no intention of or were unsure about receiving the influenza vaccine during pregnancy, those who received just the patient-level intervention were 61% more likely to receive the influenza vaccine than those in the control arm (Relative risk: 1.61; 95% Confidence Interval: 1.18-2.21). There was no significant difference in vaccine uptake for either influenza or tetanus, diphtheria and acellular pertussis between the four arms of the study.This trial highlights the need for more targeted interventions to improve vaccine uptake. Future work should focus on clinics with low baseline vaccine uptake and the patient-level intervention should be expanded and targeted towards women with low vaccine confidence.

Health care provider recommendations are among the most important factors influencing parents' decisions to vaccinate their adolescents. However, delivery of high-quality health care provider recommendations for vaccination is not universal. There is wide variation in the strength, timeliness and consistency of the delivery of recommendations for all adolescent vaccines. The factors that influence health care providers' recommendations are multi-level and can be conceptualized in much the same way as vaccine acceptance among parents. Health care providers are influenced by their own attitudes and beliefs about a vaccine and also by the patient they are treating and by the community in which they practice as well as state and national level vaccine policy. We propose a multi-level framework for understanding the factors that influence health care providers' recommendations at the individual, interpersonal and community level to both develop and adapt interventions to improve providers' recommendations.

Despite ample evidence of the safety and efficacy of the influenza vaccine and the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine during pregnancy, two-thirds of pregnant women do not receive these vaccines. Providers have a significant role in increasing prenatal vaccine uptake. It is important to understand how different sources of vaccine prescribing information, such as Food and Drug Administration package inserts, influence provider recommendations. We aimed to examine the role of vaccine package inserts in provider recommendations and perceptions of safety and effectiveness of vaccines during pregnancy. A cross-sectional survey was mailed to a random, weighted sample of American College of Obstetricians and Gynecologists Fellows living in the United States in March 2019. Providers were asked about their attitudes toward package inserts, and to evaluate sample package insert statements following two different labeling rules. Their evaluations of each rule were then compared. Of the 321 respondents, the majority (90%, 288/321) recommended and/or administered maternal vaccinations. Few respondents (7.8%, 25/321) read package inserts for information regarding vaccination. Respondents were less likely to recommend sample vaccines with Pregnancy and Lactation Labeling Rule-complying inserts (46.1%, 148/321) than vaccines with Pregnancy Category inserts (87.5%, 282/321). Although most providers did not actively utilize vaccine package inserts to inform recommendations, the previous Pregnancy Categories rule was preferred compared to the Pregnancy and Lactation Labeling Rule. Collaborative efforts to update inserts with current clinical practices for pregnancy would be valuable in reducing apprehensiveness around package inserts to generate safer and more cogent recommendations for pregnant women.

INTRODUCTION: Pertussis is a highly contagious respiratory disease that results in disproportionate morbidity and mortality in infants who have yet to receive the primary diphtheria-tetanus-pertussis vaccine series. In the preceding decades numerous countries started to pursue either prenatal vaccination of pregnant women or postpartum vaccination of caregivers to protect infants. Despite proven benefit, maternal uptake of pertussis vaccine continues to be suboptimal. AREAS COVERED: Many studies have been conducted to address the suboptimal uptake of maternal pertussis vaccination. This systematic review was undertaken to systematically identify those studies, highlight the most successful strategies and find the knowledge gaps that need to be filled over the coming years to improve vaccine uptake. Twenty-five studies were identified from six different databases. EXPERT COMMENTARY: Five different interventions were shown to be successful in promoting uptake of pertussis vaccination: (1) standing orders, (2) opt-in orders, (3) provider education, (4) on-site vaccination and (5) interactive patient education. Three major knowledge gaps were also identified that need to be filled over the coming years: (1) lack of studies in low- and middle-income countries, (2) lack of studies targeting midwives and/or home birth and (3) lack of studies on the process of vaccine communication.

Background Vaccine receipt among mid-adults remains low, with only one quarter of adults being up to date for all recommended vaccines. It is important to understand the myriad factors that influence vaccine receipt among mid-adult women to address these low rates. Methods We conducted a cross-sectional analysis of data from women ages 24–45 years collected as part of an ongoing case-control study of the effectiveness of HPV vaccine. We examined associations between demographic characteristics and healthcare utilization and receipt of individual vaccines and combinations of multiple vaccines using logistic regression analyses for three routinely recommended vaccines: tetanus, influenza and HPV. Results Among the 309 women enrolled in the study, only 19 (6.2%) were up to date for all three recommended vaccines and 41 (13.3%) had not received any of the recommended vaccines. A greater number of health care visits in the past year was associated with receipt of influenza (aOR = 6.37, 95% CI = 2.53, 16.1) and tetanus (aOR = 2.17, 95% CI = 1.14, 4.12) vaccines. White women were more likely to have received HPV vaccine (aOR = 2.39, 95% CI = 1.07, 5.36). Conclusions Uptake of recommended vaccines is low among young and mid-adult women. There is a need for greater understanding of the underlying factors influencing vaccine receipt in this population.

Although vaccines are considered one of the most effective medical interventions to prevent vaccine preventable disease and associated morbidity and mortality, a number of recent outbreaks are threatening the gains made by vaccines. Vaccine hesitancy is a key driver of vaccine refusal and has been associated with vaccine preventable outbreaks. While parents seek information from many sources to inform their vaccine decision-making process, they continue to view their child's pediatric provider as a trusted source of vaccine information. The communication that occurs between a provider and parent with regards to vaccination is critical in reducing concerns and nudging parents toward vaccine acceptance. However, vaccine-hesitant parents raise issues in this encounter that many providers feel ill-equipped to answer, due to lack of training on evidence-based communication strategies. We focus on promising approaches related to patient-provider communication within the context of vaccination. We found empirical evidence that the use of a presumptive format to recommend vaccines, motivational interviewing, and tailoring information to increase message salience are approaches that can positively affect vaccine acceptance. As providers continue to serve as important influencers in the vaccine decision-making process, it is evident that there is a need to continue to identify evidence-based, and practically implementable approaches to mitigate parental vaccine hesitancy. Providers play a key role in improving coverage rates, and therefore it is paramount to seek ways to improve how providers communicate about vaccines.

Improved uptake of adult vaccinations could substantially reduce the burden of infectious disease worldwide, however very few countries achieve high coverage of recommended adult vaccinations. Vaccine hesitancy is an important driver of low vaccine uptake among adults but no measure currently exists to capture general vaccination attitudes in this population accurately and efficiently. We utilize data from two surveys of adult vaccine attitudes and uptake conducted in fifteen countries to evaluate the Vaccination Trust Indicator (VTI). The VTI is a six-item measure intended to capture general vaccine attitudes. We utilized multivariable logistic regression to examine the association between VTI scores and self-reported receipt of the seasonal influenza vaccine, receipt of a tetanus toxoid-containing vaccine and intent to receive the flu vaccine in the next season. In the five countries with self-reported vaccine receipt data, we found that a ten-point increase in VTI score was associated with a 50% increase in odds of influenza vaccine receipt (OR = 1.55, 95% CI = 1.48, 1.62) and 25% increase in the odds of tetanus vaccine receipt (OR = 1.26, 95% CI = 1.21, 1.30). Strong associations between VTI score and vaccine receipt were found in each country except China. A strong association between VTI score and intent to receive the influenza vaccine was found in all fifteen countries. The VTI is a promising tool for assessing adult immunization attitudes with clear and immediate uses for immunization programs globally.

INTRODUCTION. Maternal vaccination is critical for improving maternal and child health. Quality Improvement (QI) models(), such as the Centers for Disease Control and Prevention’s (CDC) Assessment, Feedback, Incentives, eXchange (AFIX)() model, have not yet been adapted to maternal vaccinations. This study assesses the impact of AFIX-OB, an adapted version of AFIX for obstetric settings, on maternal vaccination rates. METHODS. Between December 2016 and May 2018, state health departments and obstetric practices in Colorado and Georgia implemented the adapted AFIX-OB model. The model addressed unique patterns in patient encounters, practice flow, health records systems and competing clinical priorities in the obstetric setting through a menu of clearly-defined QI strategies, bi-weekly technical assistance meetings with designated immunization champions, incentives for champions/staff, and adapted tools to aid each practice during implementation. Vaccination rates were assessed by random chart reviews pre- and post-intervention. RESULTS. The AFIX-OB model was evaluated in eleven obstetric practices in two states as part of a multi-level intervention to increase maternal vaccination. Post AFIX-OB implementation, documented influenza vaccination rates increased from 56% at baseline to 65% (p

Immunization is one of the most effective ways to prevent infectious diseases. However, vaccination rates are suboptimal in the United States. Obstetric providers are critical in influencing vaccine decision making among pregnant women, as trust between a patient and provider may facilitate willingness to accept vaccination. Little is known about how power between a patient and provider affects vaccine acceptance. This study explored pregnant women’s trust in obstetric providers within the context of vaccines. Using concepts from the relational theory of power, we conducted 40 in-depth interviews with a purposive sample of pregnant women from four Ob-Gyn practices each in Georgia and Colorado. Results suggest that to enhance trust, providers could gain distributive power by conveying empathy. Designated power through medical experience was associated with both trust and distrust, as some women trusted their providers because of their authority and medical credentials, while others viewed authority and experience as reasons to distrust their provider. To increase acceptance, providers should acknowledge the underlying power dynamics within these interpersonal relationships and strengthen rapport with patients through empathy and dialogue.

Background Infants too young to be fully vaccinated are vulnerable to potentially deadly influenza and pertussis infections. The cocooning strategy limits this risk by vaccinating those likely to interact with the infant and mother during this vulnerable time, such as close friends and family members. Distribution of accurate and accessible vaccine information through existing social networks could be an important tool in increasing vaccine confidence and coverage. Methods We surveyed 1095 pregnant women from diverse prenatal care practices in Georgia and Colorado. These women were surveyed through a mobile app to assess vaccine intentions, attitudes, beliefs, norms, and levels of trust, and then presented brief individually-tailored educational videos about maternal and infant vaccines and the cocooning strategy. They were then given the opportunity to refer up to six contacts to enroll in the app and receive similar vaccine education. Results Twenty-eight percent of these women referred at least one contact, with an average of 2.67 contacts per referring woman. Most referrals (93%) were partners, parents, siblings, relatives, or close friends. Attitudinal constructs significantly associated with increased likelihood of referring contacts included: intention to receive maternal influenza vaccine, perceived safety of maternal Tdap vaccine, perceived efficacy of maternal influenza vaccine, perceived susceptibility to and severity of influenza during pregnancy, and trust in vaccine information from the Centers for Disease Control and Prevention (CDC) and academic institutions. Uncertainty about infant vaccine intentions was associated with decreased likelihood of referring contacts. Conclusions Pregnant women who valued vaccination and trusted vaccine information from academic institutions were more likely to refer an educational app about vaccines than those who did not. Further research is needed to determine the potential impact of this strategy on vaccine coverage when implemented on a large scale. Trial registration The survey informing this article was part of a randomized controlled trial funded by the National Institutes of Health [clinicaltrials.gov registration number NCT02898688].

Introduction The development and initial assessment in a clinical setting of a theory-driven, individually tailored educational application (app), MomsTalkShots, focused on increasing uptake of maternal and infant vaccines is described. Methods MomsTalkShots algorithmically tailored videos based on parent needs to deliver an intervention that was specifically responsive to individual vaccine attitudes, beliefs and intentions, demographics, and source credibility. MomsTalkShots was evaluated among 1103 pregnant women recruited from 23 geographically and socio-demographically diverse obstetrician-gynecologist offices in Georgia and Colorado in 2017. Self-reported information needs were assessed pre-and post-videos and participants self-reported factors related to usability and analyzed in 2018. Results The vast majority of women reported MomsTalkShots was helpful (95%), trustworthy (94%), interesting (97%) and clear to understand (99%), none of which varied by demographics or parity. Reported usability was slightly lower among vaccine hesitant women, yet the majority reported MomsTalkShots was helpful (91%), trustworthy (85%), interesting (97%) and clear (99%). The majority of women (72%) who did not have enough vaccine information pre-videos reported enough information post-videos. Conclusions MomsTalkShots was designed to provide individually tailored vaccine information to pregnant women from a population with varied vaccine intentions, confidence and vaccine concerns. MomsTalkShots was extremely well-received among pregnant women, even among women who were initially vaccine hesitant and did not intend to vaccinate themselves and their infants according to the recommended immunization schedule. Next steps include evaluation to assess impact on vaccine uptake and expansion to adolescent and adult vaccines.

A prenatal care provider's recommendation for maternal vaccines is one of the strongest predictors of vaccine acceptance during pregnancy. Aside from basic talking points, few resources exist to help obstetric care providers effectively navigate conversations with vaccine hesitant patients. This paper describes the development and acceptability of "VaxChat," an hour-long, evidence-based video tutorial aimed at improving obstetric care providers' ability to promote maternal vaccines. Between June and November 2017, 62 obstetric care providers registered to receive continuing medical education credit for viewing VaxChat. Of the post-tutorial responses received, over 90% said VaxChat increased their knowledge of what to say to vaccine hesitant patients, increased their confidence in addressing vaccinations with their pregnant patients, and will help them improve their practice culture regarding maternal vaccine promotion. Eighty percent intend to change how they approach vaccine conversations. These data suggest VaxChat may be a welcome complement to existing provider-to-patient talking points.

Objectives Although disparities in maternal vaccine acceptance among racial/ethnic groups are well documented, the reasons for these disparities are unclear. The objective of this study was to describe differences in pregnant women’s knowledge, attitudes, beliefs, intentions, and trust regarding maternal and infant vaccines by race/ethnicity. Methods We collected survey data from 1862 pregnant women from diverse prenatal care practices in Georgia and Colorado from June 2017 through July 2018. We performed multiple logistic regressions to determine differences in intentions, knowledge, attitudes, beliefs, and trust by race/ethnicity and calculated odds ratios (ORs) and 95% CIs. Results Compared with White women, Black and Hispanic women were less confident in vaccine safety and efficacy and less likely to perceive risk of acquiring vaccine-preventable diseases, report provaccine social norms, indicate having enough vaccine knowledge, and trust vaccine information from health care providers and public health authorities. Black women were the least confident in the safety of the maternal influenza vaccine (OR = 0.37; 95% CI, 0.27-0.49); maternal tetanus, diphtheria, and acellular pertussis vaccine (OR = 0.37; 95% CI, 0.27-0.52); and infant vaccines overall (OR = 0.40; 95% CI, 0.28-0.58), and were least likely to intend to receive both maternal vaccines (OR = 0.35; 95% CI, 0.27-0.47) or all infant vaccines on time (OR = 0.45; 95% CI, 0.34-0.61) as compared with White women. Conclusions Understanding differences in behavioral constructs integral to vaccine decision making among women of different races/ethnicities can lead to tailored interventions to improve vaccine acceptance.

Background Annual influenza vaccination is recommended for all patients with cancer, but vaccine uptake data by cancer type and time since diagnosis are limited. We sought to estimate vaccination rates across different cancer types in the United States and determine whether rates vary over time since diagnosis. Methods Vaccination rates in individuals with solid tumor and hematological malignancies were estimated using data from 59 917 individuals obtained by the 2016 and 2017 National Health Interview Survey conducted by the Centers for Disease Control and Prevention. Results An average of 64% of the 5053 individuals with self-reported cancer received the influenza vaccine. Vaccination rates in men and women with solid tumors (66.6% and 60.3%, respectively) and hematological malignancies (58.1% and 59.2%, respectively) were significantly higher compared to those without cancer (38.9% and 46.8%, respectively). Lower rates were seen in uninsured patients, those younger than 45 years of age, and in African Americans with hematological malignancies but not with solid tumors. Vaccine uptake was similar regardless of time since cancer diagnosis. Conclusions Influenza vaccination rates are higher in men and women with cancer but remain suboptimal, highlighting the need for additional measures to improve vaccine compliance and prevent complications from influenza across all cancer types.

ObjectiveTo estimate the financial costs paid by individual medical researchers from meeting the article processing charges (APCs) levied by open access journals in 2019. To investigate the emotional burden to researchers using a novel metric (the APC Twitter Whinge Score).DesignCross-sectional analysis.Data sourcesScopus was used to generate two random samples of researchers, the first with a senior author article indexed in the ‘Medicine’ subject area (i.e., general researchers) and the second with an article published in the ten highest impact factor general clinical medicine journals (i.e., high-impact researchers) in 2019. For each researcher, Scopus was used to identify all first and senior author original research and review articles published in 2019. Researcher and journal information was obtained from Scopus, institutional profiles, Journal Citation Reports, publisher databases on APCs, the Directory of Open Access Journals, and individual journal websites. Twitter searches were conducted to identify and classify APC-related tweets using a novel APC Twitter Whinge Score.Main outcome measuresMedian APCs paid by general and high-impact researchers for all first and senior author research and review articles published in 2019; additionally, we examined median APCs paid by researcher gender, affiliation, training, and geographic region. APC Twitter Whinge Score.ResultsThere were 241 general and 246 high-impact researchers identified as eligible for our study. In 2019, the general and high-impact researchers published a total of 914 (median 2, interquartile range 1-5) and 1471 (4, 2-8) first or senior author research or review articles, respectively. 42% (384/914) of the articles from the general researchers and 29% (428/1471) of the articles from the high-impact medical researchers were published in fully open access journals. The median total APCs paid by general researchers in 2019 was $191 [£150] (interquartile range $0-$2500 [£0-£1960]) and the median total paid by high-impact researchers was $2900 [£2274] (interquartile range $0-$5465 [£0-£4285]); the maximum paid by a single researcher in total APCs was $30115 [£23610] and $34676 [£27186], respectively. There were no differences in total APCs paid by gender, affiliation, or training. However, high-impact researchers from the Region of the Americas had a lower median total APCs paid than those from other regions ($1695, interquartile range $0 - $3935) [£1329, £0-£3085] vs. $4800, $1888-$8290) [£3763, £1480-£6500]; PConclusionsMedical researchers in 2019 were found to have paid between 0 [£0] and $34676 [£27186] in total APCs. As journals with APCs become more common, it is important to understand the cost to researchers, especially those who may not have the funding or institutional resources to cover these costs, or we risk creating a pay-to-publish system that favors well-resourced authors from well-resources institutions and areas of the world. We also present evidence that these APCs may cause emotional damage to researchers, causing them to divert effort to moaning on Twitter. We postulate that behind this behavior may lie hidden harmful cycles of personal penury, domestic argument, insomnia, poor work relationships, inadequately prepared coffee, and even the possible use of alcohol before tweeting.What is already known on this topic-Over the past 20 years, a new model of scientific publishing has emerged that relies on digital publication rather than print distribution – open access publishing.-Open access publishing has shifted part of the financial costs of publishing from academic institutions to individual researchers and their funders, who are responsible for article processing charges that can average $2000 (£1568) to $3000 (£2352) per article.-In additional to the potential financial costs of publishing, anecdotal evidence suggests that article processing charges may lead to emotional damage to researchers, causing them to divert effort to moaning on Twitter.What this study adds-Medical researchers could be paying as much as $34676 [£27186] in total article processing charges for their first and senior research and review articles each year.-The majority of article processing charge related tweets are publicly resentful (with or without sweary language) of these journal fees, scoring in the highest two categories of the Twitter Whinge Score.-As journals with article processing charges become more common, it is important to understand the burden – financial and emotional - on researchers, especially those who may not have the funding or institutional resources to cover these costs.

This national cohort study examines National Immunization Survey–Teen to assess the association of adolescents’ ability to consent to human papillomavirus vaccination without parental involvement with vaccination rates.

Background. Maternal vaccine coverage is suboptimal, and a substantial proportion of parents have concerns about vaccines. Most parents seek out vaccine information during and immediately after their first pregnancy. No study to our knowledge has analyzed survey data to identify homogeneous groups of pregnant women based on their vaccine attitudes and beliefs. Aims. To identify homogeneity among groups of pregnant women based on their vaccine attitudes and beliefs to facilitate audience segmentation and targeting of tailored educational interventions. Method. Between June 2017 and July 2018, we surveyed 2,196 pregnant women recruited from geographically and sociodemographically diverse prenatal care practices in Georgia and Colorado. We then performed a latent class analysis to identify homogeneity among groups of pregnant women. Results. Our latent class analysis produced three groups of pregnant women: vaccine supporters (36% of women), vaccine acceptors (41%), and vaccine skeptics (23%). Discussion. The major difference between the supporters and the acceptors were whether they mostly “strongly agreed” or just “agreed” to Likert-type scale survey items assessing their vaccine attitudes and beliefs. The skeptics most frequently chose “disagree” or “don’t know” for items assessing attitudinal constructs such as confidence in vaccine safety and efficacy and disease susceptibility. However, even skeptics often chose “agree” for items assessing constructs such as disease severity and self-efficacy. Conclusions. This article provides useful insight into the homogeneity among groups of pregnant women based on their vaccine attitudes and beliefs. This knowledge should help facilitate audience segmentation and targeting of tailored educational interventions among this population.

A growing body of evidence indicates sex differences in the clinical outcomes of coronavirus disease 2019 (COVID-19)1-4. However, whether immune responses against SARS-CoV-2 differ between sexes, and whether such differences explain male susceptibility to COVID-19, is currently unknown. In this study, we examined sex differences in viral loads, SARS-CoV-2-specific antibody titers, plasma cytokines, as well as blood cell phenotyping in COVID-19 patients. By focusing our analysis on patients with mild to moderate disease who had not received immunomodulatory medications, our results revealed that male patients had higher plasma levels of innate immune cytokines and chemokines including IL-8, IL-18, and CCL5, along with more robust induction of non-classical monocytes. In contrast, female patients mounted significantly more robust T cell activation than male patients during SARS-CoV-2 infection, which was sustained in old age. Importantly, we found that a poor T cell response negatively correlated with patients’ age and was predictive of worse disease outcome in male patients, but not in female patients. Conversely, higher innate immune cytokines in female patients associated with worse disease progression, but not in male patients. These findings reveal a possible explanation underlying observed sex biases in COVID-19, and provide important basis for the development of sex-based approach to the treatment and care of men and women with COVID-19.

Background Because of the particularly severe perinatal outcomes associated with antenatal Zika virus infection, it is important for prenatal care providers to communicate Zika virus risks and strategies for prevention to their patients. Although face-to-face communication is ideal, clinic visits may not allow for in-depth discussion of all concerns. While previous studies have shown prenatal providers to be pregnant women’s most trusted sources of health information, there is little knowledge on what secondary communication modalities pregnant women prefer for receiving information from their providers about an evolving public health emergency. Methods A cross-sectional, descriptive anonymous 27-item survey was distributed to pregnant women at four clinics around Atlanta, Georgia from May 5th to June 20th, 2016. The survey assessed women’s interest in and communication preferences about prenatal topics, including Zika virus. Descriptive statistics were calculated and chi-square tests were used to evaluate associations between the primary outcomes and patient characteristics. Results Four-hundred and eight women completed the survey. The most popular resource for obtaining Zika virus information was the Centers for Disease Control and Prevention (CDC) website (73.0%). While their prenatal provider’s own website for Zika information ranked 5th among sources currently accessed for Zika information, it ranked third behind educational brochures and emails for ways in which women wanted to receive information. The characteristics of Zika virus information deemed most important were: evidence-based (87.5%), endorsed by the CDC (74.1%), and endorsed by their own provider (67.9%). Conclusion In any public health emergency affecting pregnant women, women are going to seek advice from their obstetric providers. Because providers may lack sufficient time to discuss concerns with every patient, they may consider providing patient education in other ways. For the women included in this study, educational brochures, emails and providers’ own practice websites were preferred. Providers should consider taking greater advantage of these modalities to supplement in-person exchanges, particularly during a public health emergency. Electronic supplementary material The online version of this article (10.1186/s12884-017-1516-0) contains supplementary material, which is available to authorized users.

BACKGROUND: Mandatory vaccination has been effective in maintaining high vaccination coverage in countries such as the United States. However, there are no peer-reviewed analyses of the association between mandates and both coverage and subsequent incidence of vaccine-preventable disease in Europe. METHODS: Using data from the European Centre for Disease Prevention and Control and the World Health Organization, we evaluated the relationship between country-level mandatory vaccination policies and (1) measles and pertussis vaccine coverage and (2) the annual incidence of these diseases in 29 European countries. Multivariate negative binomial and linear regression models were used to quantify these associations. RESULTS: Mandatory vaccination was associated with a 3.71 (95% confidence interval [CI]: 1.68 to 5.74) percentage point higher prevalence of measles vaccination and a 2.14 (95% CI: 0.13 to 4.15) percentage point higher prevalence of pertussis vaccination when compared with countries that did not have mandatory vaccination. Mandatory vaccination was only associated with decreased measles incidence for countries without nonmedical exemptions (adjusted incidence rate ratio = 0.14; 95% CI: 0.05 to 0.36). We did not find a significant association between mandatory vaccination and pertussis incidence. CONCLUSIONS: Mandatory vaccination and the magnitude of fines were associated with higher vaccination coverage. Moreover, mandatory vaccination was associated with lower measles incidence for countries with mandatory vaccination without nonmedical exemptions. These findings can inform legislative policies aimed at increasing vaccination coverage.

INTRODUCTION: Influenza vaccination during pregnancy can offer many benefits to both mother and infant. Despite recommendations from the Advisory Committee on Immunization Practices, vaccine coverage rates among pregnant women during pregnancy are below 40% in the United States. There is a need for a greater understanding of what interventions can improve vaccine uptake among pregnant women. AREAS COVERED: This review synthesizes the existing evidence on the effectiveness of interventions to improve maternal influenza vaccine uptake. These interventions are examined within the framework of the three psychological propositions: thoughts and feelings, social processes and changing behavior directly. EXPERT COMMENTARY: A number of promising and effective interventions were identified in this review. Nudge-based interventions that build on favorable intentions to vaccinate such as provider prompts and standing orders have demonstrated significant success in improving influenza vaccine uptake. However, substantial gaps in the literature still exist. Provider recommendations are the most important predictor of vaccine receipt among pregnant women, yet few studies evaluated intervening to improve the dialogue between patient and provider. With the potential for even more vaccines to be added to the maternal immunization schedule, it is vitally important to understand how to improve uptake.

ObjectiveTo estimate the financial costs paid by individual medical researchers from meeting the article processing charges (APCs) levied by open access journals in 2019.DesignCross-sectional analysis.Data sourcesScopus was used to generate two random samples of researchers, the first with a senior author article indexed in the ‘Medicine’ subject area (general researchers) and the second with an article published in the ten highest-impact factor general clinical medicine journals (high-impact researchers) in 2019. For each researcher, Scopus was used to identify all first and senior author original research or review articles published in 2019. Data were obtained from Scopus, institutional profiles, Journal Citation Reports, publisher databases, the Directory of Open Access Journals, and individual journal websites.Main outcome measuresMedian APCs paid by general and high-impact researchers for all first and senior author research and review articles published in 2019.ResultsThere were 241 general and 246 high-impact researchers identified as eligible for our study. In 2019, the general and high-impact researchers published a total of 914 (median 2, IQR 1–5) and 1471 (4, 2–8) first or senior author research or review articles, respectively. 42% (384/914) of the articles from the general researchers and 29% (428/1471) of the articles from the high-impact medical researchers were published in fully open access journals. The median total APCs paid by general researchers in 2019 was US$191 (US$0–US$2500) and the median total paid by high-impact researchers was US$2900 (US$0–US$5465); the maximum paid by a single researcher in total APCs was US$30115 and US$34676, respectively.ConclusionsMedical researchers in 2019 were found to have paid between US$0 and US$34676 in total APCs. As journals with APCs become more common, it is important to continue to evaluate the potential cost to researchers, especially on individuals who may not have the funding or institutional resources to cover these costs.

Human papillomavirus (HPV) vaccination is suboptimally used in the United States. Vaccination before the 13th birthday is recommended by the Advisory Committee on Immunization Practices and vaccination before the 15th birthday requires only 2 doses. We estimated the proportion of adolescents up to date for HPV vaccine using provider-verified vaccination data from the 2016 National Immunization Survey-Teen. Only 16% of US adolescents completed HPV vaccination before turning 13, and 35% completed HPV vaccination before turning 15. With sexual activity initiation increasing throughout adolescence and higher immunogenicity for younger vaccinees, vaccination before the 13th birthday can provide better protection against HPV-related cancers.

Objective: Prenatal providers are pregnant women's most trusted sources of health information, and a provider's recommendation is a strong predictor of maternal vaccine receipt. However, other ways women prefer receiving vaccine-related information from prenatal providers, aside from face-to-face conversations, is unclear. This study explores what secondary communication methods are preferred for receiving maternal vaccine-related information. Study design: Obstetric patients at four prenatal clinics around Atlanta, Georgia received a 27-item survey between May 5th, 2016 and June 15th, 2016. Participants were asked about sources they currently use to obtain prenatal health information and their preferences for receiving vaccine-related information from providers. Descriptive statistics were calculated and chi-square tests were used to evaluate associations between participant characteristics and outcomes. Results: Women primarily reported using the CDC website (57.7%) and pregnancy-related websites (53.0%) to obtain vaccine information. Apart from clinical conversations, educational brochures (64.9%) and e-mails (54.7%) were the preferred methods of receiving vaccine information from providers, followed by their provider's practice website (42.1%). Communication preferences and interest in maternal immunization varied by race/ethnicity, age and education; white women were twice as likely to want information on a provider's practice website compared to African-American women (OR = 2.06; 95% CI: 1.31, 3.25). Conclusions: Pregnant women use the Internet for information about vaccines, but they still value input from their providers. While e-mails and brochures were the preferred secondary modes of receiving information, a provider's existing practice website offers a potential communications medium that capitalizes on women's information seeking behaviors and preferences while limiting burden on providers.

Background Influenza and Tdap vaccines are recommended for pregnant women in every pregnancy. However, vaccine uptake remains suboptimal. Obstetrics practices need quality improvement models to improve their vaccination delivery programs. CDC’s AFIX program has been shown to be effective at increasing vaccination uptake in primary care settings. Our objective was to adapt and evaluate CDC’s AFIX program in the obstetrical setting (AFIIX-OB). Methods An average of 40 charts per practice were randomly reviewed pre- and post-intervention. Baseline immunization rates and vaccine administration practices were collected in the Assessment phase. Feedback was provided at meetings conducted by study staff where baseline immunization rates were shared and practices selected quality improvement measures to implement. Practices were required to implement either standing orders for influenza and Tdap vaccines or improve their vaccine documentation. As an Incentive, providers could receive continuing medical education and maintenance of certification part IV credit. After implementing the practice specific measures for 6 months, practice-wide vaccine rates were assessed and a post-intervention meeting was held with providers and staff at each practice to eXchange the results. Results AFIX-OB was implemented in 11 obstetric practices: 5 in Georgia and 6 in Colorado. Practices were primarily urban, their patients largely Caucasian and African American and most patients carried private insurance. Baseline practice-level immunization rates ranged from 10% to 82.9% for influenza vaccine and 12.5% to 97.6% for Tdap. 4 practices implemened standing orders, 6 improved their vaccine documentation and 1 did both. After the 6 month follow-up period, all 11 practices saw improvements in their overall Tdap vaccine acceptance (3 with statistically significant increases, P < 0.05) with final rates ranging from 25% to 100%. 9 practices either maintained or improved their influenza vaccination rates (4 with statistically significant increases, P < 0.05) with final rates ranging from 32.5% to 85.0%. Conclusion The AFIX-OB model provides a promising intervention to improve maternal immunization uptake that can be administered widely but still be tailored to the needs of individual clinics. Disclosures All authors: No reported disclosures.

Background: Pregnant women are frequently a priority group during public health emergencies, including the current Zika virus outbreak. These women turn to prenatal care providers for health information, but providers may not have the time for discussions with every patient. Knowing alternative ways to communicate key Zika-related information to pregnant women is important. Methods: To determine pregnant women’s preferences for obtaining Zika information from their prenatal providers, a 27-item survey was administered to 408 pregnant women at four prenatal care clinics in Atlanta between May 5th, 2016 and June 20th, 2016. The anonymous survey evaluated women’s preferences for receiving information about three topics: Zika virus, maternal vaccines and safe medications. Chi-square and Fisher’s exact tests were used to determine statistical significance of associations between these topics and selected patient characteristics. Significance was evaluated at α=0.05. Results: Educational brochures (63.8%), e-mails (55.2%) and their provider’s practice website (40.2%) were women’s most preferred modalities for receiving information about Zika virus beyond verbal communication. Most women (73.2%) use the CDC website as their primary source of information about Zika virus; only 19.2% seek that information on their provider’s website. Conclusions: Conveying Zika-related information to pregnant women is essential. As public health practitioners create and refine provider-to-patient communications, they can use these findings to ensure their messages align with how women want to receive information (e.g., brochures, emails, provider websites) and take advantage of existing modalities (e.g. their own websites) that providers may not be fully utilizing. Key words: Zika virus, pregnancy, communication, internet, social media, prenatal care providers