Persuading the "Movable Middle”: Characteristics of Effective Messages to Promote Routine and COVID-19 Vaccinations for Adults and Children – The Impact of COVID-19 on Beliefs and Attitudes

Purpose We sought to 1) explore trusted sources for vaccine information, 2) describe persuasive characteristics of trusted messages promoting routine and COVID-19 vaccines for children and adults and 3) explore how the pandemic has impacted attitudes and beliefs about routine vaccinations. We conducted a mixed method cross-sectional study between May 3-June 14, 2021 including a survey and six focus groups among a sub-set of survey respondents. A total of 1,553 survey respondents (from which n=33 participated in the focus groups) including adults without children under age nineteen years (n=582) and parents with children under age nineteen years (n=971). Results Primary care providers, family, and credible sources, characterized as known and well-established entities, were top sources of vaccine information. Neutrality, honesty, and having a trusted source to rely on in sorting through volumes of sometimes conflicting information were highly valued. Trustworthy qualities about sources included: 1) expertise, 2) fact-based, 3) unbiased, and 4) having an established process for sharing information. Because of the evolving nature of the pandemic, attitudes and beliefs about COVID-19 vaccine and sources of COVID-19 information differed from typical views about routine vaccines. Of 1,327 (85.4%) survey respondents, 12.7% and 9.4% of adults and parents cited that the pandemic impacted their attitudes and beliefs. Among these respondents, 8% of adults and 3% of parents cited more favorable attitudes and beliefs about getting vaccinated with routine vaccines because of the pandemic. Conclusion Vaccine attitudes and beliefs which inform intent to vaccinate can change and differ among different vaccines. Messaging should be tailored to resonate with parents and adults to improve vaccine uptake.

Trusted messengers and trusted messages: The role for community-based organizations in promoting COVID-19 and routine immunizations.

We sought to explore the trust and influence community-based organizations have within the communities they serve to inform public health strategies in tailoring vaccine and other health messages. A qualitative study was conducted between March 15 - April 12, 2021 of key informants in community-based organizations serving communities in and around Philadelphia, Pennsylvania. These organizations serve communities with high Social Vulnerability Index scores. We explored four key questions including: (1) What was and continues to be the impact of COVID-19 on communities; (2) How have trust and influence been cultivated in the community; (3) Who are trusted sources of information and health messengers; and (4) What are the community's perceptions about vaccines, vaccinations, and intent to vaccinate in the context of the COVID-19 pandemic. Fifteen key informants from nine community-based organizations who serve vulnerable populations (e.g., mental health, homeless, substance use, medically complex, food insecurity) were interviewed. Five key findings include: (1) The pandemic has exacerbated disparities in existing social determinants of health for individuals and families and have created new concerns for these communities; (2) components of how to build the trust and influence (e.g., demonstrate empathy, create a safe space, deliver on results)resonated with key informants; (3) regardless of the source, presenting health information in a respectful and understandable manner is key to effective delivery; (4) trust and influence can be transferred by association to a secondary messenger connected to or introduced by the primary trusted source; and (5) increased awareness about vaccines and vaccinations offers opportunities to think differently, changing previously held beliefs or attitudes, as many individuals are now more cognizant of risks associated with vaccine-preventable diseases and the importance of vaccines. Community-based organizations offer unique opportunities to address population-level health disparities as trusted vaccine messengers to deliver public health messages.

Persuading the "Movable Middle": Characteristics of effective messages to promote routine and COVID-19 vaccinations for adults and children - The impact of COVID-19 on beliefs and attitudes.

PURPOSE: We sought to 1) explore trusted sources for vaccine information, 2) describe persuasive characteristics of trusted messages promoting routine and COVID-19 vaccines for children and adults and 3) explore how the pandemic has impacted attitudes and beliefs about routine vaccinations. We conducted a mixed method cross-sectional study between May 3-June 14, 2021 including a survey and six focus groups among a sub-set of survey respondents. A total of 1,553 survey respondents (from which n = 33 participated in the focus groups) including adults without children under age nineteen years (n = 582) and parents with children under age nineteen years (n = 971). RESULTS: Primary care providers, family, and credible sources, characterized as known and well-established entities, were top sources of vaccine information. Neutrality, honesty, and having a trusted source to rely on in sorting through volumes of sometimes conflicting information were highly valued. Trustworthy qualities about sources included: 1) expertise, 2) fact-based, 3) unbiased, and 4) having an established process for sharing information. Because of the evolving nature of the pandemic, attitudes and beliefs about COVID-19 vaccine and sources of COVID-19 information differed from typical views about routine vaccines. Of 1,327 (85.4 %) survey respondents, 12.7 % and 9.4 % of adults and parents cited that the pandemic impacted their attitudes and beliefs. Among these respondents, 8 % of adults and 3 % of parents cited more favorable attitudes and beliefs about getting vaccinated with routine vaccines because of the pandemic. CONCLUSION: Vaccine attitudes and beliefs which inform intent to vaccinate can change and differ among different vaccines. Messaging should be tailored to resonate with parents and adults to improve vaccine uptake.

Comparing COVID-19 Vaccination Outcomes with Parental Values, Beliefs, Attitudes, and Hesitancy Status, 2021-2022.

Despite the availability of safe and effective COVID-19 vaccines, vaccine acceptance has been low, particularly among parents. More information is needed on parental decision-making. We conducted a prospective cohort study from October 2021 to March 2022 among 334 parents in a large urban/suburban pediatric primary care network and linked longitudinal survey responses about attitudes and beliefs on vaccination, social norms, and access to vaccination services for COVID-19 to electronic health-record-derived vaccination outcomes for their eldest age-eligible children in June 2022. The odds of accepting two doses of COVID-19 vaccine for their child was higher in respondents who indicated the COVID-19 vaccine would be very safe (aOR [CI]: 2.69 [1.47-4.99], p = 0.001), as well as those who previously vaccinated their child against influenza (aOR [CI]: 4.07 [2.08-8.12], p < 0.001). The odds of vaccinating their child were lower for respondents who attended suburban vs. urban practices (aOR [CI]: 0.38 [0.21-0.67], p = 0.001). Parents in the cohort were active users of social media; the majority (78%) used their phone to check social media platforms at least once per day. Our findings suggest that healthcare providers and policymakers can focus on improving vaccination coverage among children living in suburban neighborhoods through targeted mobile-based messaging emphasizing safety to their parents.

Using a patient portal as a recruitment tool to diversify the pool of participants in COVID-19 vaccine clinical trials.

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected racial/ethnic minorities in the United States, who are underrepresented in clinical trials. We assessed the feasibility of using the University of Pennsylvania Health System electronic health record patient portal to diversify the pool of participants in COVID-19 vaccine clinical trials. The patient portal was used to send invitations to eligible individuals living in zip codes with high rates of racial/ethnic minorities. The 5614 invited consisted of 96.7% black, 1.3% Hispanic/Latinx, and 1.5% white. The overall response rate was 5.4%, with lower response rates among Black (3.8%) and Hispanic/Latinx (9.6%) as compared to white individuals (91.6%). Among respondents, black individuals had lower rates of interest in participating (26.7%), as compared to white (65.8%) and Hispanic/Latinx (71.4%) individuals. Of 115 respondents who expressed interest, 9 enrolled in the clinical trial, which included 6 black, 3 white, and 1 Hispanic/Latinx. During phone outreach to nonresponders and decliners, common reasons for declining included mistrust of the COVID-19 vaccine, underlying health conditions, and logistical barriers to trial participation. Because of low rates of patient portal account activation and use, compounded with vaccine hesitancy, this method yielded a small number of interested individuals.

Design, Implementation, and Outcomes of a Volunteer-Staffed Case Investigation and Contact Tracing Initiative at an Urban Academic Medical Center.

Importance: The COVID-19 pandemic has claimed nearly 6 million lives globally as of February 2022. While pandemic control efforts, including contact tracing, have traditionally been the purview of state and local health departments, the COVID-19 pandemic outpaced health department capacity, necessitating actions by private health systems to investigate and control outbreaks, mitigate transmission, and support patients and communities. Objective: To investigate the process of designing and implementing a volunteer-staffed contact tracing program at a large academic health system from April 2020 to May 2021, including program structure, lessons learned through implementation, results of case investigation and contact tracing efforts, and reflections on how constrained resources may be best allocated in the current pandemic or future public health emergencies. Design, Setting, and Participants: This case series study was conducted among patients at the University of Pennsylvania Health System and in partnership with the Philadelphia Department of Public Health. Patients who tested positive for COVID-19 were contacted to counsel them regarding safe isolation practices, identify and support quarantine of their close contacts, and provide resources, such as food and medicine, needed during isolation or quarantine. Results: Of 5470 individuals who tested positive for COVID-19 and received calls from a volunteer, 2982 individuals (54.5%; median [range] age, 42 [18-97] years; 1628 [59.4%] women among 2741 cases with sex data) were interviewed; among 2683 cases with race data, there were 110 Asian individuals (3.9%), 1476 Black individuals (52.7%), and 817 White individuals (29.2%), and among 2667 cases with ethnicity data, there were 366 Hispanic individuals (13.1%) and 2301 individuals who were not Hispanic (82.6%). Most individuals lived in a household with 2 to 5 people (2125 of 2904 individuals with household data [71.6%]). Of 3222 unique contacts, 1780 close contacts (55.2%; median [range] age, 40 [18-97] years; 866 [55.3%] women among 1565 contacts with sex data) were interviewed; among 1523 contacts with race data, there were 69 Asian individuals (4.2%), 705 Black individuals (43.2%), and 573 White individuals (35.1%), and among 1514 contacts with ethnicity data, there were 202 Hispanic individuals (12.8%) and 1312 individuals (83.4%) who were not Hispanic. Most contacts lived in a household with 2 to 5 people (1123 of 1418 individuals with household data [79.2%]). Of 3324 cases and contacts who completed a questionnaire on unmet social needs, 907 (27.3%) experienced material hardships that would make it difficult for them to isolate or quarantine safely. Such hardship was significantly less common among White compared with Black participants (odds ratio, 0.20; 95% CI, 0.16-0.25). Conclusions and Relevance: These findings demonstrate the feasibility and challenges of implementing a case investigation and contact tracing program at an academic health system. In addition to successfully engaging most assigned COVID-19 cases and close contacts, contact tracers shared health information and material resources to support isolation and quarantine, thus filling local public health system gaps and supporting local pandemic control.

Factors Influencing Parental and Individual COVID-19 Vaccine Decision Making in a Pediatric Network.

Aspects of the COVID-19 vaccination campaign differed from routine vaccines, including emergency use authorizations, the prioritization of access, and the politicization of messaging. Subsequently, many parents reported lower vaccine confidence relative to routine vaccines, and vaccination coverage stalled below targets. This study aimed to understand parental vaccine decision making and compare COVID-19 versus routine vaccine decision making. We conducted nine virtual focus groups between 25 February 2022-11 March 2022 with parents (n = 41) of the Children's Hospital of Philadelphia's patients, recruited via email and stratified by vaccine hesitancy status (non-hesitant vs. hesitant). Transcripts were analyzed using the vaccine hesitancy matrix domains. Of 41 total participants, 25 (61.0%) were non-hesitant, 16 (39.0%) were hesitant or their children were not up-to-date on adolescent vaccines, and most self-identified as female (95.1%) and White/Caucasian (61.0%). Most participants (87.5%) were fully vaccinated against COVID-19 and many of their first children (n = 26, 63.4%) were vaccinated against influenza. Several themes emerged regarding decision making: individual influences, group influences, vaccine and vaccine program influences, and contextual influences. While some influences were similar for routine and COVID-19 vaccine decision making (e.g., needing evidence-based information), other factors were vaccine- or situation-specific. Building trust requires a multi-faceted concerted effort that involves addressing the complex vaccine decision-making process.

Genomic Analysis of AZD1222 (ChAdOx1) Vaccine Breakthrough Infections in the City of Mumbai

Background This manuscript describes the genetic features of SARS-CoV-2 mutations, prevalent phylogenetic lineages, and the disease severity amongst COVID-19-vaccinated individuals in a tertiary cancer hospital during the second wave of the pandemic in Mumbai, India. Methods This observational study included 159 COVID-19 patients during the second wave of the pandemic from 17th March to 1st June 2021 at a tertiary cancer care centre in Mumbai. The cohort comprised of healthcare workers, staff relatives, cancer patients, and patient relatives. For comparison, 700 SARS-CoV-2 genomes sequenced during the first wave (23rd April to 25th September 2020) at the same centre were also analysed. Patients were assigned to nonvaccinated (no vaccination or <14 days from the 1st dose, n = 92), dose 1(≥14 days from the 1st dose to <14 days from the 2nd dose, n = 29), and dose 2 (≥14 days from the 2nd dose, n = 38) groups. Primary measure was the prevalence of SARS-CoV-2 genomic lineages among different groups. In addition, severity of COVID-19 was assessed according to clinical and genomic variables. Results Kappa B.1.1671.1 and delta B.1.617.2 variants contributed to an overwhelming majority of sequenced genomes (unvaccinated: 40/92, 43.5% kappa, 46/92, 50% delta;dose 1: 14/29, 48.3% kappa, 15/29, 51.7% delta;and dose 2: 23/38, 60.5% kappa, 14/38 36.8% delta). The proportion of the kappa and delta variants did not differ significantly across the unvaccinated, dose 1, and dose 2 groups (p = 0.27). There was no occurrence of severe COVID-19 in the dose 2 group (0/38, 0% vs. 14/121, 11.6%;p = 0.02). SARS-CoV-2 genomes from all three severe COVID-19 patients in the vaccinated group belonged to the delta lineage (3/28, 10.7% vs. 0/39, 0.0%, p = 0.04). Conclusions Sequencing analysis of SARS-COV-2 genomes from Mumbai during the second wave of COVID-19 suggests the prevalence of the kappa B.1.617.1 and the delta B.1.627.2 variants among both vaccinated and unvaccinated individuals. Continued evaluation of genomic sequencing data from breakthrough COVID-19 is necessary for monitoring the properties of evolving variants of concern and formulating appropriate immune response boosting and therapeutic strategies.

Disadvantage Indices Deployed to Promote Equitable Allocation of COVID-19 Vaccines in the US : A Scoping Review of Differences and Similarities in Design

This scoping review identifies the construction and defined purpose of disadvantage indices deployed during the initial COVID-19 vaccine rollout.

Genomic Analysis of AZD1222 (ChAdOx1) Vaccine Breakthrough Infections in the City of Mumbai.

Background: This manuscript describes the genetic features of SARS-CoV-2 mutations, prevalent phylogenetic lineages, and the disease severity amongst COVID-19-vaccinated individuals in a tertiary cancer hospital during the second wave of the pandemic in Mumbai, India. Methods: This observational study included 159 COVID-19 patients during the second wave of the pandemic from 17th March to 1st June 2021 at a tertiary cancer care centre in Mumbai. The cohort comprised of healthcare workers, staff relatives, cancer patients, and patient relatives. For comparison, 700 SARS-CoV-2 genomes sequenced during the first wave (23rd April to 25th September 2020) at the same centre were also analysed. Patients were assigned to nonvaccinated (no vaccination or <14 days from the 1st dose, n = 92), dose 1(≥14 days from the 1st dose to <14 days from the 2nd dose, n = 29), and dose 2 (≥14 days from the 2nd dose, n = 38) groups. Primary measure was the prevalence of SARS-CoV-2 genomic lineages among different groups. In addition, severity of COVID-19 was assessed according to clinical and genomic variables. Results: Kappa B.1.1671.1 and delta B.1.617.2 variants contributed to an overwhelming majority of sequenced genomes (unvaccinated: 40/92, 43.5% kappa, 46/92, 50% delta; dose 1: 14/29, 48.3% kappa, 15/29, 51.7% delta; and dose 2: 23/38, 60.5% kappa, 14/38 36.8% delta). The proportion of the kappa and delta variants did not differ significantly across the unvaccinated, dose 1, and dose 2 groups (p = 0.27). There was no occurrence of severe COVID-19 in the dose 2 group (0/38, 0% vs. 14/121, 11.6%; p = 0.02). SARS-CoV-2 genomes from all three severe COVID-19 patients in the vaccinated group belonged to the delta lineage (3/28, 10.7% vs. 0/39, 0.0%, p = 0.04). Conclusions: Sequencing analysis of SARS-COV-2 genomes from Mumbai during the second wave of COVID-19 suggests the prevalence of the kappa B.1.617.1 and the delta B.1.627.2 variants among both vaccinated and unvaccinated individuals. Continued evaluation of genomic sequencing data from breakthrough COVID-19 is necessary for monitoring the properties of evolving variants of concern and formulating appropriate immune response boosting and therapeutic strategies.

Disadvantage Indices Deployed to Promote Equitable Allocation of COVID-19 Vaccines in the US: A Scoping Review of Differences and Similarities in Design.

This scoping review identifies the construction and defined purpose of disadvantage indices deployed during the initial COVID-19 vaccine rollout.