Many studies have examined behavioral and social drivers of COVID-19 vaccination initiation, but few have examined these drivers longitudinally. We sought to identify the drivers of COVID-19 vaccination initiation using the Behavioral and Social Drivers of Vaccination (BeSD) Framework. Participants were a nationally-representative sample of 1,563 US adults who had not received a COVID-19 vaccine by baseline. Participants took surveys online at baseline (spring 2021) and follow-up (fall 2021). The surveys assessed variables from BeSD Framework domains (i.e., thinking and feeling, social processes, and practical issues), COVID-19 vaccination initiation, and demographics at baseline and follow-up. Between baseline and follow-up, 65% of respondents reported initiating COVID-19 vaccination. Vaccination intent increased from baseline to follow-up (p < .01). Higher vaccine confidence, more positive social norms towards vaccination, and receiving vaccine recommendations at baseline predicted subsequent COVID-19 vaccine initiation (all p < .01). Among factors assessed at follow-up, social responsibility and vaccine requirements had the greatest associations with vaccine initiation (all p < .01). Baseline vaccine confidence, social norms, and vaccination recommendations were associated with subsequent vaccine initiation, all of which could be useful targets for behavioral interventions. Furthermore, interventions that highlight social responsibility to vaccinate or promote vaccination requirements could also be beneficial.

In October 2020, the CDC's Vaccinate with Confidence strategy specific to COVID-19 vaccines rollout was published. Adapted from an existing vaccine confidence framework for childhood immunization, the Vaccinate with Confidence strategy for COVID-19 aimed to improve vaccine confidence, demand, and uptake of COVID-19 vaccines in the US. The objectives for COVID-19 were to 1. build trust, 2. empower healthcare personnel, and 3. engage communities and individuals. This strategy was implemented through a dedicated unit, the Vaccine Confidence and Demand (VCD) team, which collected behavioral insights; developed and disseminated toolkits and best practices in collaboration with partners; and collaborated with health departments and community-based organizations to engage communities and individuals in behavioral interventions to strengthen vaccine demand and increase COVID-19 vaccine uptake. The VCD team collected and used social and behavioral data through establishing the Insights Unit, implementing rapid community assessments, and conducting national surveys. To strengthen capacity at state and local levels, the VCD utilized "Bootcamps," a rapid training of trainers on vaccine confidence and demand, "Confidence Consults", where local leaders could request tailored advice to address local vaccine confidence challenges from subject matter experts, and utilized surge staffing to embed "Vaccine Demand Strategists" in state and local public health agencies. In addition, collaborations with Prevention Research Centers, the Institute of Museum and Library Services, and the American Psychological Association furthered work in behavioral science, community engagement, and health equity. The VCD team operationalized CDC's COVID-19 Vaccine with Confidence strategy through behavioral insights, capacity building opportunities, and collaborations to improve COVID-19 vaccine confidence, demand, and uptake in the US. The inclusion of applied behavioral science approaches were a critical component of the COVID-19 vaccination program and provides lessons learned for how behavioral science can be integrated in future emergency responses.

INTRODUCTION: Around one-third of Americans reported they were unwilling to get a COVID-19 vaccine in April 2021. This focus group study aimed to provide insights on the factors contributing to unvaccinated adults' hesitancy or refusal to get vaccinated with COVID-19 vaccines. METHOD: Ipsos recruited 59 unvaccinated US adults who were vaccine hesitant (i.e., conflicted about or opposed to receiving a COVID-19 vaccination) using the Ipsos KnowledgePanel. Trained facilitators led a total of 10 focus groups via video-conference in March and April 2021. Two coders manually coded the data from each group using a coding frame based on the focus group discussion guide. The coding team collaborated in analyzing the data for key themes. RESULTS: Data analysis of transcripts from the focus groups illuminated four main themes associated with COVID-19 vaccine hesitancy: lack of trust in experts and institutions; concern about the safety of COVID-19 vaccines; resistance towards prescriptive guidance and restrictions; and, despite personal reluctance or unwillingness to get vaccinated, acceptance of others getting vaccinated. DISCUSSION: Vaccine confidence communication strategies should address individual concerns, describe the benefits of COVID-19 vaccination, and highlight evolving science using factural and neutral presentations of information to foster trust.

INTRODUCTION: COVID-19 vaccines are safe, effective, and widely available, but many adults in the U.S. have not been vaccinated for COVID-19. This study examined the associations between behavioral and social drivers of vaccination with COVID-19 vaccine uptake in the U.S. adults and their prevalence by region. METHODS: A nationally representative sample of U.S. adults participated in a cross-sectional telephone survey in August-November 2021; the analysis was conducted in January 2022. Survey questions assessed self-reported COVID-19 vaccine initiation, demographics, and behavioral and social drivers of vaccination. RESULTS: Among the 255,763 respondents, 76% received their first dose of COVID-19 vaccine. Vaccine uptake was higher among respondents aged ≥75 years (94%), females (78%), and Asian non-Hispanic people (94%). The drivers of vaccination most strongly associated with uptake included higher anticipated regret from nonvaccination, risk perception, and confidence in vaccine safety and importance, followed by work- or school-related vaccination requirements, social norms, and provider recommendation (all p<0.05). The direction of association with uptake varied by reported level of difficulty in accessing vaccines. The prevalence of all of these behavioral and social drivers of vaccination was highest in the Northeast region and lowest in the Midwest and South. CONCLUSIONS: This nationally representative survey found that COVID-19 vaccine uptake was most strongly associated with greater anticipated regret, risk perception, and confidence in vaccine safety and importance, followed by vaccination requirements and social norms. Interventions that leverage these social and behavioral drivers of vaccination have the potential to increase COVID-19 vaccine uptake and could be considered for other vaccine introductions.

A young man with X-linked severe combined immunodeficiency developed a persistent vaccine-derived rubella virus (VDRV) infection, with the emergence of cutaneous granulomas more than fifteen years after receipt of two doses of measles-mumps-rubella (MMR) vaccine. Following nasopharyngeal swab (NP) collection, VDRV was detected by real-time polymerase chain reaction (RT-qPCR) and sequencing, and live, replication-competent VDRV was isolated in cell culture. To assess duration and intensity of viral shedding, sequential respiratory samples, one cerebrospinal fluid sample, and two urine samples were collected over 15 months, and VDRV RNA was detected in all samples by RT-qPCR. Live VDRV was cultured from nine of the eleven respiratory specimens and from one urine specimen. To our knowledge, this was the first reported instance of VDRV cultured from respiratory specimens or from urine. To assess potential transmission to close contacts, NP specimens and sera were collected from all household contacts, all of whom were immunocompetent and previously vaccinated with MMR. VDRV RNA was not detected in any NP swabs from the contacts, nor did serologic investigations suggest VDRV transmission to any contacts. This report highlights the need to understand the prevalence and duration of VDRV shedding in granuloma patients and to estimate the risk of VDRV transmission to immune and non-immune contacts.

COVID-19 vaccine coverage in the US has marked demographic and geographical disparities, but few explanations exist for them. Our paper aimed to identify behavioral and social drivers that explain these vaccination disparities. Participants were a national sample of 3562 American adults, recruited from the Ipsos KnowledgePanel. Participants completed an online survey in spring 2021, when COVD-19 vaccination was available for higher-risk groups but not yet available to all US adults. The survey assessed COVID-19 vaccination stage (intentions and vaccine uptake), constructs from the Increasing Vaccination Model (IVM) domains (thinking and feeling, social processes, and direct behavior change), self-reported exposure to COVID-19 vaccine information, and demographic characteristics. Analyses used multiple imputation to address item nonresponse and linear regressions to conduct mediation analyses. Higher COVID-19 vaccination stage was strongly associated with older age, liberal political ideology, and higher income in adjusted analyses (all p < .001). Vaccination stage was more modestly associated with urbanicity, white race, and Hispanic ethnicity (all p < .05). Some key mediators that explained more than one-third of demographic differences in vaccination stage were perceived vaccine effectiveness, social norms, and recommendations from family and friends across most demographic characteristics (all p < .05). Other mediators included safety concerns, trust, altruism, provider recommendation, and information seeking. Access to vaccination, barriers to vaccination, and self-efficacy explained few demographic differences. One of the most reliable explanations for demographic differences in COVID-19 vaccination stage is social processes, including social norms, recommendations, and altruism. Interventions to promote COVID-19 vaccination should address social processes and other domains in the IVM.

INTRODUCTION: Employer vaccination requirements have been used to increase vaccination uptake among healthcare personnel (HCP). In summer 2021, HCP were the group most likely to have employer requirements for COVID-19 vaccinations as healthcare facilities led the implementation of such requirements. This study examined the association between employer requirements and HCP's COVID-19 vaccination status and attitudes about the vaccine. METHODS: Participants were a national representative sample of United States (US) adults who completed the National Immunization Survey Adult COVID Module (NIS-ACM) during August-September 2021. Respondents were asked about COVID-19 vaccination and intent, requirements for vaccination, place of work, attitudes surrounding vaccinations, and sociodemographic variables. This analysis focused on HCP respondents. We first calculated the weighted proportion reporting COVID-19 vaccination for HCP by sociodemographic variables. Then we computed unadjusted and adjusted prevalence ratios for vaccination coverage and key indicators on vaccine attitudes, comparing HCP based on individual self-report of vaccination requirements. RESULTS: Of 12,875 HCP respondents, 41.5% reported COVID-19 vaccination employer requirements. Among HCP with vaccination requirements, 90.5% had been vaccinated against COVID-19, as compared to 73.3% of HCP without vaccination requirements-a pattern consistent across sociodemographic groups. Notably, the greatest differences in uptake between HCP with and without employee requirements were seen in sociodemographic subgroups with the lowest vaccination uptake, e.g., HCP aged 18-29 years, HCP with high school or less education, HCP living below poverty, and uninsured HCP. In every sociodemographic subgroup examined, vaccine uptake was more equitable among HCP with vaccination requirements than in HCP without. Finally, HCP with vaccination requirements were also more likely to express confidence in the vaccine's safety (68.3% vs. 60.1%) and importance (89.6% vs 79.6%). CONCLUSION: In a large national US sample, employer requirements were associated with higher and more equitable HCP vaccination uptake across all sociodemographic groups examined. Our findings suggest that employer requirements can contribute to improving COVID-19 vaccination coverage, similar to patterns seen for other vaccines.

On August 16, 2021, the Oregon Health Authority Public Health Division (OPHD) was notified of two pediatric cases of Shiga toxigenic Escherichia coli among members of the same household. Each of the patients received a positive polymerase chain reaction test result for Shiga toxin in a stool specimen. E. coli O157:H7 was subsequently isolated from stool culture from both patients. During routine case investigation, the local health department determined that one patient, aged 2 years, had attended an in-home child care center. OPHD visited the child care center on August 18 to conduct case ascertainment among staff members and children, share recommendations for rapid isolation and exclusion of those ill, observe infection prevention practices during diaper changing, and educate staff members on infection prevention measures for toys and high-touch surfaces. The investigation team requested parental consent and attempted to collect clinical information on gastrointestinal symptoms during July 30–August 18 and stool specimens from all staff members and children on the day of the visit. A child care center staff member followed up with other staff members and children who were not present on the day of the visit to obtain clinical information and provide them with specimen collection kits and instructions. Stool specimens were placed in Cary-Blair transport medium, transported to OPHD, and tested for 22 enteric pathogens using the BioFire FilmArray Gastrointestinal Panel (BioFire Diagnostics, LLC).

IMPORTANCE: Contact tracing is a multistep process to limit SARS-CoV-2 transmission. Gaps in the process result in missed opportunities to prevent COVID-19. OBJECTIVE: To quantify proportions of cases and their contacts reached by public health authorities and the amount of time needed to reach them and to compare the risk of a positive COVID-19 test result between contacts and the general public during 4-week assessment periods. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study took place at 13 health departments and 1 Indian Health Service Unit in 11 states and 1 tribal nation. Participants included all individuals with laboratory-confirmed COVID-19 and their named contacts. Local COVID-19 surveillance data were used to determine the numbers of persons reported to have laboratory-confirmed COVID-19 who were interviewed and named contacts between June and October 2020. MAIN OUTCOMES AND MEASURES: For contacts, the numbers who were identified, notified of their exposure, and agreed to monitoring were calculated. The median time from index case specimen collection to contact notification was calculated, as were numbers of named contacts subsequently notified of their exposure and monitored. The prevalence of a positive SARS-CoV-2 test among named and tested contacts was compared with that jurisdiction's general population during the same 4 weeks. RESULTS: The total number of cases reported was 74 185. Of these, 43 931 (59%) were interviewed, and 24 705 (33%) named any contacts. Among the 74 839 named contacts, 53 314 (71%) were notified of their exposure, and 34 345 (46%) agreed to monitoring. A mean of 0.7 contacts were reached by telephone by public health authorities, and only 0.5 contacts per case were monitored. In general, health departments reporting large case counts during the assessment (≥5000) conducted smaller proportions of case interviews and contact notifications. In 9 locations, the median time from specimen collection to contact notification was 6 days or less. In 6 of 8 locations with population comparison data, positive test prevalence was higher among named contacts than the general population. CONCLUSIONS AND RELEVANCE: In this cross-sectional study of US local COVID-19 surveillance data, testing named contacts was a high-yield activity for case finding. However, this assessment suggests that contact tracing had suboptimal impact on SARS-CoV-2 transmission, largely because 2 of 3 cases were either not reached for interview or named no contacts when interviewed. These findings are relevant to decisions regarding the allocation of public health resources among the various prevention strategies and for the prioritization of case investigations and contact tracing efforts.