BACKGROUND: Adults who are hesitant toward routinely recommended vaccines for adults may also be hesitant toward COVID-19 vaccines. However, the distribution and differences in hesitancy between routinely recommended vaccines and COVID-19 vaccines, and the association of hesitancy regarding routinely recommended vaccines and hesitancy with COVID-19 vaccination status and intent, is unknown. METHODS: Using the Research and Development Survey (RANDS) during COVID-19, Round 3, a probability-sampled, nationally representative, web and phone survey fielded from May 17 - June 30, 2021 (n = 5,434), we examined the distribution and difference in prevalence of hesitancy towards COVID-19 and vaccines in general, beliefs associated with vaccine hesitancy, and factors impacting plans to be vaccinated against COVID-19. RESULTS: Reported hesitancy towards COVID-19 vaccines (42.2%) was 6-percentage points higher than hesitancy towards vaccines in general (35.7%). Populations who were most hesitant toward COVID-19 vaccines were younger adults, non-Hispanic Black adults, adults with lower education or income, and adults who were associated with a religion. Beliefs in the social benefit and the importance of vaccination, and the belief that COVID-19 vaccines lower risk for infection, were strongly associated with COVID-19 vaccination and intent to be vaccinated. CONCLUSIONS: Vaccine hesitancy for both COVID-19 vaccines and vaccines in general is common. Health providers and public health officials should utilize strategies to address vaccine hesitancy, including providing strong clear recommendations for needed vaccines, addressing safety and effectiveness concerns, and utilizing trusted messengers such as religious and community leaders to improve vaccine confidence.

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. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license.

Objectives. To identify promising practices for implementing COVID-19 vaccination sites. Methods. The Centers for Disease Control and Prevention (CDC) and Federal Emergency Management Agency (FEMA) assessed high-throughput COVID-19 vaccination sites across the United States, including Puerto Rico, after COVID-19 vaccinations began. Site assessors conducted site observations and interviews with site staff. Qualitative data were compiled and thematically analyzed. Results. CDC and FEMA conducted 134 assessments of high-throughput vaccination sites in 25 states and Puerto Rico from February 12 to May 28, 2021. Promising practices were identified across facility, clinical, and cross-cutting operational areas and related to 6 main themes: addressing health equity, leveraging partnerships, optimizing site design and flow, communicating through visual cues, using quick response codes, and prioritizing risk management and quality control. Conclusions. These practices might help planning and implementation of future vaccination operations for COVID-19, influenza, and other vaccine-preventable diseases. Public Health Implications. These practices can be considered by vaccination planners and providers to strengthen their vaccination site plans and implementation of future high-throughput vaccination sites. (Am J Public Health. 2023;113(8):909-918. https://doi.org/10.2105/AJPH.2023.307331).

This article describes perceptions of the COVID-19 vaccine among US adults, and reports that younger adults, women, non-Hispanic Black adults, adults living in nonmetropolitan areas, adults with less education and income, and adults without health insurance have the highest estimates of nonintent to receive vaccination; due to concerns about side effects and safety of the COVID-19 vaccine, lack of trust in the government, and concern that COVID-19 vaccines were developed too quickly are the primary reasons for deferring vaccination. Solid organ transplant candidates and recipients may harbor similar concerns about vaccination, and further, may rely more heavily on herd immunity for protection from COVID-19, since the efficacy of COVID-19 vaccination among immunosuppressed individuals remains ill-defined. Promoting vaccine confidence among transplant candidates, transplant recipients, and the general population will thus be critical to preventing spread of COVID-19.

BACKGROUND: The role of vaccine hesitancy on influenza vaccination is not clearly understood. Low influenza vaccination coverage in U.S. adults suggests that a multitude of factors may be responsible for under-vaccination or non-vaccination including vaccine hesitancy. Understanding the role of influenza vaccination hesitancy is important for targeted messaging and intervention to increase influenza vaccine confidence and uptake. The objective of this study was to quantify the prevalence of adult influenza vaccination hesitancy (IVH) and examine association of IVH beliefs with sociodemographic factors and early-season influenza vaccination. METHODS: A four-question validated IVH module was included in the 2018 National Internet Flu Survey. Weighted proportions and multivariable logistic regression models were used to identify correlates of IVH beliefs. RESULTS: Overall, 36.9% of adults were hesitant to receive an influenza vaccination; 18.6% expressed concerns about vaccination side effects; 14.8% personally knew someone with serious side effects; and 35.6% reported that their healthcare provider was not the most trusted source of information about influenza vaccinations. Influenza vaccination ranged from 15.3 to 45.2 percentage points lower among adults self-reporting any of the four IVH beliefs. Being female, age 18-49 years, non-Hispanic Black, having high school or lower education, being employed, and not having primary care medical home were associated with hesitancy. CONCLUSIONS: Among the four IVH beliefs studied, being hesitant to receiving influenza vaccination followed by mistrust of healthcare providers were identified as the most influential hesitancy beliefs. Two in five adults in the United States were hesitant to receive an influenza vaccination, and hesitancy was negatively associated with vaccination. This information may assist with targeted interventions, personalized to the individual, to reduce hesitancy and thus improve influenza vaccination acceptance.

Water bodies that serve as sources of drinking or recreational water are routinely monitored for fecal indicator bacteria (FIB) by state and local agencies. Exceedances of monitoring thresholds set by those agencies signal likely elevated human health risk from exposure, but FIB give little information about the potential source of contamination. To improve our understanding of how within-day variation could impact monitoring data interpretation, we conducted a study at two sites along the Chattahoochee River that varied in their recreational usage and adjacent land-use (natural versus urban), collecting samples every 30 min over one 24-h period. We assayed for three types of microbial indicators: FIB (total coliforms and Escherichia coli); human fecal-associated microbial source tracking (MST) markers (crAssphage and HF183/BacR287); and a suite of clinically relevant antibiotic resistance genes (ARGs; blaCTX-M, blaCMY, MCR, KPC, VIM, NDM) and a gene associated with antibiotic resistance (intl1). Mean levels of FIB and clinically relevant ARGs (blaCMY and KPC) were similar across sites, while MST markers and intI1 occurred at higher mean levels at the natural site. The human-associated MST markers positively correlated with antibiotic resistant-associated genes at both sites, but no consistent associations were detected between culturable FIB and any molecular markers. For all microbial indicators, generalized additive mixed models were used to examine diurnal variability and whether this variability was associated with environmental factors (water temperature, turbidity, pH, and sunlight). We found that FIB peaked during morning and early afternoon hours and were not associated with environmental factors. With the exception of HF183/BacR287 at the urban site, molecular MST markers and intI1 exhibited diurnal variability, and water temperature, pH, and turbidity were significantly associated with this variability. For blaCMY and KPC, diurnal variability was present but was not correlated with environmental factors. These results suggest that differences in land use (natural or urban) both adjacent and upstream may impact overall levels of microbial contamination. Monitoring agencies should consider matching sample collection times with peak levels of target microbial indicators, which would be in the morning or early afternoon for the fecal associated indicators. Measuring multiple microbial indicators can lead to clearer interpretations of human health risk associated with exposure to contaminated water.

Understanding the role of vaccine hesitancy in undervaccination or nonvaccination of childhood vaccines is important for increasing vaccine confidence and uptake. We used data from April to June interviews in the 2018 and 2019 National Immunization Survey-Flu (n = 78,725, United States), a nationally representative cross-sectional household cellular telephone survey. We determined the adjusted population attributable fraction (PAF) for each recommended childhood vaccine to assess the contribution of vaccine hesitancy to the observed nonvaccination level. Hesitancy is defined as being somewhat or very hesitant toward childhood vaccines. Furthermore, we assessed the PAF of nonvaccination for influenza according to sociodemographic characteristics, Department of Health and Human Services region, and state. The proportion of nonvaccination attributed to parental vaccine hesitancy was lowest for hepatitis B birth dose vaccine (6.5%) and highest for ≥3-dose diphtheria and tetanus toxoids and acellular pertussis vaccine (31.3%). The PAF of influenza nonvaccination was highest for non-Hispanic Black populations (15.4%), households with high educational (17.7%) and income (16.5%) levels, and urban areas (16.1%). Among states, PAF ranged from 25.4% (New Hampshire) to 7.5% (Louisiana). Implementing strategies to increase vaccination confidence and uptake are important, particularly during the coronavirus disease 2019 pandemic.

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.

BACKGROUND: Pregnant and postpartum women are at increased risk for severe illness from COVID-19. We assessed COVID-19 vaccination coverage, intent, and attitudes among women of reproductive age overall and by pregnancy status in the United States. METHODS: Data from the National Immunization Survey Adult COVID Module collected during April 22-November 27, 2021, were analyzed to assess COVID-19 vaccination (receipt of 1 dose), intent for vaccination, and attitudes towards vaccination among women aged 18-49years overall and by pregnancy status (trying to get pregnant, currently pregnant, breastfeeding, and not trying to get pregnant or currently pregnant or breastfeeding). Logistic regression and predictive marginals were used to generate unadjusted and adjusted prevalence ratios (PRs and aPRs). Trend analyses were conducted to assess monthly changes in vaccination and intent. RESULTS: Our analyses included 110,925 women aged 18-49years. COVID-19 vaccination coverage (1 dose) was 63.2% overall (range from 53.3% in HHS Region 4 to 76.5% in HHS Region 1). Vaccination coverage was lowest among pregnant women (45.1%), followed by women who were trying to get pregnant (49.5%), women who were breastfeeding (51.5%), and all other women (64.9%). Non-Hispanic (NH) Black women who were pregnant or breastfeeding had significantly lower vaccination coverage (aPR: 0.74 and 0.66, respectively) than NH White women. DISCUSSION: Our findings are consistent with other studies showing lower vaccination coverage among pregnant individuals, with substantially lower vaccination coverage among NH Black women who are pregnant or breastfeeding. Given the overlapping and disproportionate risks of COVID-19 and maternal mortality among Black women, it is critical that COVID-19 vaccination be strongly recommended for these populations and all women of reproductive age. Healthcare and public health providers may take advantage of every opportunity to encourage vaccination and enlist the assistance of community leaders, particularly in communities with low vaccination coverage.

OBJECTIVES: National data on COVID-19 vaccination coverage among pregnant women are limited. We assessed COVID-19 vaccination coverage and intent, factors associated with COVID-19 vaccination, reasons for nonvaccination, and knowledge, attitudes, and beliefs related to COVID-19 illness and vaccination among pregnant women in the United States. METHODS: Data from an opt-in internet panel survey of pregnant women conducted March 31-April 16, 2021, assessed receipt of 1 dose of any COVID-19 vaccine during pregnancy. The sample included 1516 women pregnant any time during December 1, 2020-April 16, 2021, who were not fully vaccinated before pregnancy. We used multivariable logistic regression to determine variables independently associated with receipt of COVID-19 vaccine. RESULTS: As of April 16, 2021, 21.7% of pregnant women had received 1 dose of COVID-19 vaccine during pregnancy, 24.0% intended to receive a vaccine, 17.2% were unsure, and 37.1% did not intend to receive a vaccine. Pregnant women with (vs without) a health care provider recommendation (adjusted prevalence ratio [aPR] = 4.86), those who lived (vs not) with someone with a condition that could increase risk for serious medical complications of COVID-19 (aPR = 2.11), and those who had received (vs not) an influenza vaccination (aPR = 2.35) were more likely to receive a COVID-19 vaccine. Common reasons for nonvaccination included concerns about safety risk to baby (37.2%) or self (34.6%) and about rapid vaccine development (29.7%) and approval (30.9%). CONCLUSIONS: Our findings indicate a continued need to emphasize the benefits of COVID-19 vaccination during pregnancy and to widely disseminate the recommendations of the Centers for Disease Control and Prevention and other clinical professional societies for all pregnant women to be vaccinated.

INTRODUCTION: Parental vaccine hesitancy can be a barrier to routine childhood immunization and contribute to greater risk for vaccine-preventable diseases. This study examines the impact of parental vaccine hesitancy on childhood vaccination rates. METHODS: This study assessed the association of parental vaccine hesitancy on child vaccination coverage with ≥4 doses of diphtheria, tetanus toxoid, and acellular pertussis vaccine; ≥1 dose of measles, mumps, and rubella vaccine; up-to-date rotavirus vaccine; and combined 7-vaccine series coverage for a sample of children aged 19-35 months using data from the 2018 and 2019 National Immunization Survey-Child (N=7,645). Adjusted differences in multivariable analyses of vaccination coverage were estimated among vaccine hesitant and nonhesitant parents and population attributable risk fraction of hesitancy on undervaccination, defined as not being up to date for each vaccine. RESULTS: Almost a quarter of parents reported being vaccine hesitant, with the highest proportion of vaccine hesitancy among parents of children who are non-Hispanic Black (37.0%) or Hispanic (30.1%), mothers with a high school education or less (31.9%), and households living below the poverty level (35.6%). Childhood vaccination coverage for all vaccines was lower for children of hesitant than nonhesitant parents, and the population attributable fraction of hesitancy on undervaccination ranged from 15% to 25%, with the highest percentage for ≥1 dose of measles, mumps, and rubella vaccine. CONCLUSIONS: Parental vaccine hesitancy may contribute up to 25% of undervaccination among children aged 19-35 months. Implementation of strategies to address parental vaccine hesitancy is needed to improve vaccination coverage for children and minimize their risk of vaccine-preventable diseases.

INTRODUCTION: Healthcare personnel are at increased risk for COVID-19 from workplace exposure. National estimates on COVID-19 vaccination coverage among healthcare personnel are limited. METHODS: Data from an opt-in Internet panel survey of 2,434 healthcare personnel, conducted on March 30, 2021-April 15, 2021, were analyzed to assess the receipt of ≥1 dose of a COVID-19 vaccine and vaccination intent. Multivariable logistic regression was used to assess the factors associated with COVID-19 vaccination and intent for vaccination. RESULTS: Overall, 68.2% of healthcare personnel reported a receipt of ≥1 dose of a COVID-19 vaccine, 9.8% would probably/definitely get vaccinated, 7.1% were unsure, and 14.9% would probably/definitely not get vaccinated. COVID-19 vaccination coverage was highest among physicians (89.0%), healthcare personnel working in hospitals (75.0%), and healthcare personnel of non-Hispanic White or other race (75.7%-77.4%). Healthcare personnel who received influenza vaccine in 2020-2021 (adjusted prevalence ratio=1.92) and those aged ≥60 years (adjusted prevalence ratio=1.37) were more likely to report a receipt of ≥1 dose of a COVID-19 vaccine. Non-Hispanic Black healthcare personnel (adjusted prevalence ratio=0.74), nurse practitioners/physician assistants (adjusted prevalence ratio=0.55), assistants/aides (adjusted prevalence ratio=0.73), and nonclinical healthcare personnel (adjusted prevalence ratio=0.79) were less likely to have received a COVID-19 vaccine. The common reasons for vaccination included protecting self (88.1%), family and friends (86.3%), and patients (69.2%) from COVID-19. The most common reason for nonvaccination was concern about side effects and safety of COVID-19 vaccine (59.7%). CONCLUSIONS: Understanding vaccination status and intent among healthcare personnel is important for addressing barriers to vaccination. Addressing concerns on side effects, safety, and effectiveness of COVID-19 vaccines as well as their fast development and approval may help improve vaccination coverage among healthcare personnel.

Vaccination is critical to controlling the COVID-19 pandemic, and health care providers play an important role in achieving high vaccination coverage (1). To examine the prevalence of report of a provider recommendation for COVID-19 vaccination and its association with COVID-19 vaccination coverage and attitudes, CDC analyzed data among adults aged ≥18 years from the National Immunization Survey-Adult COVID Module (NIS-ACM), a nationally representative cellular telephone survey. Prevalence of report of a provider recommendation for COVID-19 vaccination among adults increased from 34.6%, during April 22-May 29, to 40.5%, during August 29-September 25, 2021. Adults who reported a provider recommendation for COVID-19 vaccination were more likely to have received ≥1 dose of a COVID-19 vaccine (77.6%) than were those who did not receive a recommendation (61.9%) (adjusted prevalence ratio [aPR] = 1.12). Report of a provider recommendation was associated with concern about COVID-19 (aPR = 1.31), belief that COVID-19 vaccines are important to protect oneself (aPR = 1.15), belief that COVID-19 vaccination was very or completely safe (aPR = 1.17), and perception that many or all of their family and friends had received COVID-19 vaccination (aPR = 1.19). Empowering health care providers to recommend vaccination to their patients could help reinforce confidence in, and increase coverage with, COVID-19 vaccines, particularly among groups known to have lower COVID-19 vaccination coverage, including younger adults, racial/ethnic minorities, and rural residents.

We assessed coronavirus disease vaccination and intent and knowledge, attitudes, and beliefs among essential workers during March-June 2021. Coverage was 67%; 18% reported no intent to get vaccinated. Primary concerns were potential side effects, safety, and lack of trust in vaccines, highlighting the importance of increasing vaccine confidence in this population.

BACKGROUND: Approximately 20,000 people died from influenza in the US in the 2019 - 2020 season. The best way to prevent influenza is to receive the influenza vaccine. Persons who are foreign-born experience disparities in access to, and utilization of, preventative healthcare, including vaccination. METHODS: National Health Interview Survey (NHIS) data were analyzed to assess differences in influenza vaccination coverage during the 2012-13 through 2017-18 influenza seasons among adults by nativity, citizenship status of foreign-born persons, race/ethnicity, and language of the interview. RESULTS: Influenza vaccination coverage increased significantly during the study period for US-born adults but did not change significantly among foreign-born racial/ethnic groups except for increases among foreign-born Hispanic adults. Coverage for foreign-born adults, those who completed an interview in a non-English language, and non-US citizens, had lower vaccination coverage during most influenza seasons studied, compared with US-born, English-interviewed, and US-citizen adults, respectively. CONCLUSION: Strategies to improve influenza vaccination uptake must consider foreign-born adults as an underserved population in need of focused, culturally-tailored outreach. Achieving high influenza vaccination coverage among the foreign-born population will help reduce illness among the essential workforce, achieve national vaccination goals, and reduce racial and ethnic disparities in vaccination coverage in the US.

Since April 19, 2021, all persons aged ≥16 years in the United States have been eligible to receive a COVID-19 vaccine. As of May 30, 2021, approximately one half of U.S. adults were fully vaccinated, with the lowest coverage and lowest reported intent to get vaccinated among young adults aged 18-39 years (1-4). To examine attitudes toward COVID-19 vaccination and vaccination intent among adults in this age group, CDC conducted nationally representative household panel surveys during March-May 2021. Among respondents aged 18-39 years, 34.0% reported having received a COVID-19 vaccine. A total of 51.8% were already vaccinated or definitely planned to get vaccinated, 23.2% reported that they probably were going to get vaccinated or were unsure about getting vaccinated, and 24.9% reported that they probably or definitely would not get vaccinated. Adults aged 18-24 years were least likely to report having received a COVID-19 vaccine and were most likely to report being unsure about getting vaccinated or that they were probably going to get vaccinated. Adults aged 18-39 years with lower incomes, with lower educational attainment, without health insurance, who were non-Hispanic Black, and who lived outside of metropolitan areas had the lowest reported vaccination coverage and intent to get vaccinated. Concerns about vaccine safety and effectiveness were the primary reported reasons for not getting vaccinated. Vaccination intent and acceptance among adults aged 18-39 years might be increased by improving confidence in vaccine safety and efficacy while emphasizing that vaccines are critical to prevent the spread of COVID-19 to friends and family and for resuming social activities (5).

Despite the Advisory Committee on Immunization Practices’ (ACIP) recommendations for routine vaccination of adolescents, vaccination coverage remains low for many adolescent vaccines, particularly the human papillomavirus (HPV) vaccine [1]. In 2018, 68.1% of adolescents aged 13–17 years had received ≥ 1 dose of HPV vaccine, and only 51.1% were up to date with the HPV vaccine series, well below the Healthy People 2020 target of 80% [2,3]. More efforts are needed to understand barriers to vaccination and improve coverage for all recommended vaccines in this population.

As of February 8, 2021, 59.3 million doses of vaccines to prevent coronavirus disease 2019 (COVID-19) had been distributed in the United States, and 31.6 million persons had received at least 1 dose of the COVID-19 vaccine (1). However, national polls conducted before vaccine distribution began suggested that many persons were hesitant to receive COVID-19 vaccination (2). To examine perceptions toward COVID-19 vaccine and intentions to be vaccinated, in September and December 2020, CDC conducted household panel surveys among a representative sample of U.S. adults. From September to December, vaccination intent (defined as being absolutely certain or very likely to be vaccinated) increased overall (from 39.4% to 49.1%); the largest increase occurred among adults aged ≥65 years. If defined as being absolutely certain, very likely, or somewhat likely to be vaccinated, vaccination intent increased overall from September (61.9%) to December (68.0%). Vaccination nonintent (defined as not intending to receive a COVID-19 vaccination) decreased among all adults (from 38.1% to 32.1%) and among most sociodemographic groups. Younger adults, women, non-Hispanic Black (Black) persons, adults living in nonmetropolitan areas, and adults with lower educational attainment, with lower income, and without health insurance were most likely to report lack of intent to receive COVID-19 vaccine. Intent to receive COVID-19 vaccine increased among adults aged ≥65 years by 17.1 percentage points (from 49.1% to 66.2%), among essential workers by 8.8 points (from 37.1% to 45.9%), and among adults aged 18-64 years with underlying medical conditions by 5.3 points (from 36.5% to 41.8%). Although confidence in COVID-19 vaccines increased during September-December 2020 in the United States, additional efforts to tailor messages and implement strategies to further increase the public's confidence, overall and within specific subpopulations, are needed. Ensuring high and equitable vaccination coverage across all populations is important to prevent the spread of COVID-19 and mitigate the impact of the pandemic.

OBJECTIVES: To quantify the prevalence of parental vaccine hesitancy (VH) in the United States and examine the association of VH with sociodemographics and childhood influenza vaccination coverage. METHODS: A 6-question VH module was included in the 2018 and 2019 National Immunization Survey-Flu, a telephone survey of households with children age 6 months to 17 years. RESULTS: The percentage of children having a parent reporting they were "hesitant about childhood shots" was 25.8% in 2018 and 19.5% in 2019. The prevalence of concern about the number of vaccines a child gets at one time impacting the decision to get their child vaccinated was 22.8% in 2018 and 19.1% in 2019; the prevalence of concern about serious, long-term side effects impacting the parent's decision to get their child vaccinated was 27.3% in 2018 and 21.7% in 2019. Only small differences in VH by sociodemographic variables were found, except for an 11.9 percentage point higher prevalence of "hesitant about childhood shots" and 9.9 percentage point higher prevalence of concerns about serious, long-term side effects among parents of Black compared with white children. In both seasons studied, children of parents reporting they were "hesitant about childhood shots" had 26 percentage points lower influenza vaccination coverage compared with children of parents not reporting hesitancy. CONCLUSIONS: One in 5 children in the United States have a parent who is vaccine hesitant, and hesitancy is negatively associated with childhood influenza vaccination. Monitoring VH could help inform immunization programs as they develop and target methods to increase vaccine confidence and vaccination coverage.

INTRODUCTION: Coerced and forced sexual initiation (FSI) can have detrimental effects on children and youth. Understanding health outcomes that are associated with experiences of FSI is important for developing appropriate strategies for prevention and treatment of FSI and its consequences. METHODS: The Violence Against Children Surveys were conducted in Nigeria, Uganda, and Zambia in 2014 and 2015. We examined the prevalence of FSI and its consequences (sexual high-risk behaviors, violence experiences, mental health outcomes, and sexually transmitted infections (STI)) associated with FSI among youth aged 13-24 years in three countries in sub-Saharan Africa. RESULTS: Over one in ten youth aged 13-24 years who had ever had sex experienced FSI in Nigeria, Uganda, and Zambia. In multivariable logistic regression, FSI was significantly associated with infrequent condom use (OR=1.4, 95%CI=1.1-2.1), recent experiences of sexual violence (OR=1.6, 95%CI: 1.1-2.3), physical violence (OR=2.2, 95%CI: 1.6-3.0), and emotional violence (OR=2.0, 95%CI: 1.3-2.9), moderate/serious mental distress (OR=1.5, 95%CI: 1.1-2.0), hurting oneself (OR=2.0, 95%CI: 1.3-3.1), and thoughts of suicide (OR=1.5, 95%CI: 1.1-2.3), after controlling for demographic characteristics. FSI was not statistically associated with engaging in transactional sex, having multiple sex partners, or having a STI. CONCLUSION: FSI is associated with infrequent condom use, recent experiences of violence and mental health outcomes among youth in sub-Saharan Africa, which may increase the risk for HIV and other consequences. Developing strategies for prevention is important for reducing the prevalence of FSI and its effects on children and youth.

Children's exposure to poly-victimization, which is the experience of multiple types of victimization, has been found to be associated with negative health outcomes and risk behaviors. We examined the collective effects of childhood sexual, physical, and emotional violence on selected self-reported health outcomes among young Kenyan females and males using the Violence Against Children Survey (VACS). Overall, 76.2% of females and 79.8% of males were victims of sexual, physical, or emotional violence prior to age 18, and one-third (32.9% and 34.5%, respectively) experienced two or more types of violence. Poly-victimization was significantly associated with current feelings of anxiety, depression, and suicidal thoughts in females and males, as well as self-reported fair or poor health in males (p < .05) as compared to those who experienced no violence. The study data demonstrate an urgent need to reduce all types of violence against children, as well develop appropriate strategies for its prevention.

INTRODUCTION: Globally 1 billion children are exposed to violence every year. The Violence Against Children Surveys (VACS) are nationally representative surveys of males and females ages 13-24 that are intended to measure the burden of sexual, physical and emotional violence experienced in childhood, adolescence and young adulthood. It is important to document the methodological approach and design of the VACS to better understand the national estimates that are produced in each country, which are used to drive violence prevention efforts. METHODS: This study describes the surveys' target population, sampling design, statistical considerations, data collection process, priority violence indicators and data dissemination. RESULTS: Twenty-four national household surveys have been completed or are being planned in countries across Africa, Asia, the Caribbean, Central and South America, and Eastern Europe. The sample sizes range from 891 to 7912 among females (72%-98% response rate) and 803-2717 among males (66%-98% response rate). Two face-to-face interviews are conducted: a Household and an Individual Questionnaire. A standard set of core priority indicators are generated for each country that range from prevalence of different types of violence, contexts, risk and protective factors, and health consequences. Results are disseminated through various platforms to expand the reach and impact of the survey results. CONCLUSION: Data obtained through VACS can inform development and implementation of effective prevention strategies and improve health service provision for all who experience violence. VACS serves as a standardised tool to inform and drive prevention through high-quality, comprehensive data.

Understanding factors that are associated with disclosure of sexual violence (SV) is important for the delivery of health services as well as developing strategies for prevention and response. The Violence Against Children Surveys were conducted in Malawi and Nigeria. We examined the prevalence of SV, help-seeking behaviors, and factors associated with disclosure among girls and young women aged 13 to 24. The self-reported prevalence of SV was similar in Nigeria (26%) and Malawi (27%). Among females who experienced SV, approximately one third (37%) in Nigeria and one half (55%) in Malawi ever disclosed their experience of SV. Females in Nigeria were significantly more likely to disclose to their parents (31.8%) than females in Malawi (9.5%). The most common reason for nondisclosure in Nigeria was not feeling a need or desire to tell anyone (34.9%) and in Malawi was embarrassment (29.3%). Very close relationships with one or both parents were significantly associated with disclosure among Nigerian females (odds ratio [OR] = 5.5, 95% confidence interval [CI] = [2.1, 14.6]) but were inversely associated with disclosure among Malawian females (OR = 0.05, 95% CI = [0.01, 0.33]). Reasons for nondisclosure of SV and factors associated with disclosure among females differ in the African nations studied. The stigma associated with shame of SV may prevent females from disclosing and thus receiving necessary support and health, social, and other services. This study demonstrates a need to reduce barriers for disclosure to improve the delivery of health, social, and other response services across African nations, as well as to develop culturally appropriate strategies for its response.

INTRODUCTION: The US Surgeon General has concluded that e-cigarette aerosol is not harmless and can contain harmful and potentially harmful chemicals, including nicotine. We assessed factors associated with adults' perceptions of harm related to children's exposure to secondhand aerosol from electronic vapor products (EVPs). METHODS: Data came from the 2015 Styles, an Internet panel survey of US adults aged 18 years or older (n = 4,127). Respondents were asked whether they believe aerosol from other people's EVPs causes children harm. Harm perceptions were assessed overall and by cigarette smoking, EVP use, and sociodemographic characteristics. Multinomial logistic regression was used to assess odds of perceived harm. RESULTS: Overall, 5.3% of adults responded that secondhand EVP exposure caused "no harm" to children, 39.9% responded "little harm" or "some harm," 21.5% responded "a lot of harm," and 33.3% responded "don't know." Odds of "no harm" response were greater among men than among women, current and former cigarette smokers than among never smokers, and current and former EVP users than among never users; odds were lower among non-Hispanic blacks, Hispanics, and non-Hispanic other races than among non-Hispanic whites. Odds of responding "don't know" were greater among men, current cigarette smokers, and current and former EVP users; odds were lower among those aged 45 to 64 years than those aged 18 to 24 years and lower among non-Hispanic other races and Hispanics than non-Hispanic whites. CONCLUSION: Two-fifths of US adults believe that children's exposure to secondhand EVP aerosol causes some or little harm, while one-third do not know whether it causes harm. Efforts are warranted to educate the public about the health risks of secondhand EVP aerosol, particularly for children.

INTRODUCTION: Research suggests aerosol from electronic vapor products (EVPs) has fewer harmful constituents than conventional cigarette smoke. Even so, EVPs and other nicotine-containing products are not safe to use during pregnancy. We examined perceptions among US adults regarding harm in using EVPs rather than smoking cigarettes during pregnancy. METHODS: Data came from the 2015 Styles Survey, an Internet panel survey of a sample of US adults aged 18 years or older (N = 4,127). Perceived harm was assessed by asking respondents whether using EVPs was less, equally, or more harmful for pregnant women than smoking cigarettes. Descriptive statistics were used to estimate perceived harm overall and by sociodemographic characteristics and tobacco-use status. Perceived harm was assessed among all adults, women of reproductive age (18-44 years, n = 820), and women of nonreproductive age (≥45 years, n = 1,398). RESULTS: Among all adults, 11.1% believed using EVPs during pregnancy was less harmful than smoking conventional cigarettes, 51.0% believed it was equally harmful, 11.6% believed it was more harmful, and 26.2% did not know. Prevalence of perception of less harm, by demographic category, was greatest among adults aged 18 to 24 years, men, non-Hispanic whites, adults with less than a high school diploma, current EVP users, and current cigarette smokers (P < .05). Prevalence of perception of less harm was greater among women of reproductive age (9.6%) than among those of nonreproductive age (7.9%) (P < .05). CONCLUSION: US adults have varying levels of perceptions about the harms of EVP use versus cigarette smoking during pregnancy. Efforts are warranted to prevent nicotine exposure during pregnancy and to educate adults on the dangers of using any form of tobacco during pregnancy, including EVPs.

Tobacco use is the leading cause of preventable disease and death in the United States, resulting in approximately 480,000 premature deaths and more than $300 billion in direct health care expenditures and productivity losses each year. In recent years, cigarette smoking prevalence has declined in many states; however, there has been relatively little change in the prevalence of current smokeless tobacco use or concurrent use of cigarettes and smokeless tobacco in most states, and in some states prevalence has increased. CDC analyzed data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS) to assess state-specific prevalence estimates of current use of cigarettes, smokeless tobacco, and cigarette and/or smokeless tobacco (any cigarette/smokeless tobacco use) among U.S. adults. Current cigarette smoking ranged from 9.7% (Utah) to 26.7% (West Virginia); current smokeless tobacco use ranged from 1.4% (Hawaii) to 8.8% (Wyoming); current use of any cigarette and/or smokeless tobacco product ranged from 11.3% (Utah) to 32.2% (West Virginia). Disparities in tobacco use by sex and race/ethnicity were observed; any cigarette and/or smokeless tobacco use was higher among males than females in all 50 states. By race/ethnicity, non-Hispanic whites had the highest prevalence of any cigarette and/or smokeless tobacco use in eight states, followed by non-Hispanic other races in six states, non-Hispanic blacks in five states, and Hispanics in two states (p<0.05); the remaining states did not differ significantly by race/ethnicity. Evidence-based interventions, such as increasing tobacco prices, implementing comprehensive smoke-free policies, conducting mass media anti-tobacco use campaigns, and promoting accessible smoking cessation assistance, are important to reduce tobacco use and tobacco-related disease and death among U.S. adults, particularly among subpopulations with the highest use prevalence.

INTRODUCTION: Multiunit housing (MUH) residents are particularly susceptible to involuntary secondhand smoke (SHS) exposure in their home, which can enter their living units from nearby units and shared areas where smoking occurs. To date, no study has assessed non-cigarette tobacco use among MUH residents. This study assessed the prevalence and sociodemographic correlates of tobacco use (combustible, noncombustible, any tobacco use including electronic cigarettes), smoke-free home rules, and SHS incursions among U.S. MUH residents. METHODS: Data came from the 2013-2014 National Adult Tobacco Survey, a telephone survey of U.S. adults aged ≥18 years. Analyses were conducted in 2015. Prevalence of current tobacco use and smoke-free home rules were assessed overall and by sociodemographics, stratified by housing type (single family versus MUH). Prevalence and adjusted odds of SHS incursions among MUH residents with smoke-free home rules were assessed. RESULTS: Tobacco use was higher among adults living in MUH (24.7%) than those in single-family housing (18.9%, p<0.05). Smoke-free home rules were higher among adults living in single-family housing (86.7%) than those in MUH (80.9%, p<0.05). Among MUH residents with smoke-free homes, 34.4% experienced SHS incursions. Adjusted odds of SHS incursions were greater among women, younger adults, non-Hispanic blacks, Hispanics, and those with lower income. CONCLUSIONS: One quarter of MUH residents use tobacco, and one third of MUH residents with smoke-free rules experience SHS incursions. Interventions are warranted to promote tobacco cessation and smoke-free building policies to protect all MUH residents, employees, and visitors from the dangers of tobacco use and SHS.

INTRODUCTION: Electronic nicotine delivery system (ENDS) use has increased rapidly in the U.S. in recent years. The availability and use of ENDS raise new issues for public health practice and tobacco regulation, as it is unknown whether patterns of ENDS use enhance, deter, or have no impact on combustible tobacco product use. This study assessed past-month, lifetime, and frequency of ENDS use among current, former, and never adult cigarette smokers. METHODS: Data were analyzed from the 2014 Styles, a national consumer-based probability-based web panel survey of U.S. adults aged ≥18 years (n=4,269) conducted during June and July. Lifetime ENDS users were defined as those who reported having used ENDS ≥1 day in their lifetime. Past-month ENDS users were defined as those who reported using ENDS in the past 30 days. RESULTS: In 2014, overall lifetime and past-month ENDS use was 14.1% and 4.8%, respectively. By smoking status, 49.5% of current, 14.7% of former, and 4.1% of never cigarette smokers had used ENDS in their lifetime, whereas 20.6% of current, 4.0% of former, and 0.8% of never smokers used ENDS in the past month. Among current and former cigarette smokers who ever used ENDS, 44.1% and 44.7% reported using ENDS >10 days in their lifetime, respectively. CONCLUSIONS: Because the effect ENDS use has on combustible tobacco products use is unknown, and lifetime and past-month ENDS use is more common among current than former or never smokers, continued surveillance of ENDS use among adults is critical to programs and policies.

OBJECTIVE: Many states have implemented laws prohibiting tobacco smoking in indoor public places. However, private settings remain a major source of secondhand smoke (SHS) exposure for many people. We assessed the association between current asthma and SHS exposure in vehicles among adult never-smokers in Indiana, Kentucky, Louisiana and Mississippi. METHODS: Data came from the 2011 Behavioral Risk Factor Surveillance System, a state-based telephone survey of US adults aged ≥18 years. Analyses were restricted to states (n=4) that administered an optional SHS module. Prevalence of self-reported asthma and past 7-day SHS exposure in vehicles was calculated by demographics, voluntary smoke-free vehicle rules and SHS exposure in homes, public places and workplaces. Logistic regression was used to assess the adjusted association between asthma and SHS exposure in vehicles. RESULTS: Among 17 863 never-smoking adults, 7.4% reported having current asthma, whereas 12.3% reported past 7-day SHS exposure in vehicles. Among adults with asthma, SHS exposure in vehicles was lower among those with voluntary smoke-free rules compared with those without voluntary smoke-free rules (9.5% vs 56.7%, p<0.0001). Following adjustment, adults exposed to SHS in a vehicle had a higher odds of having current asthma compared with unexposed adults (OR=2.01, 95% CI 1.18 to 3.40). CONCLUSIONS: Never-smoking adults recently exposed to SHS in a vehicle had higher odds of having current asthma compared with unexposed adults. Efforts are warranted to warn about the dangers of SHS and to encourage voluntary smoke-free rules in vehicles, especially among adults with asthma.

BACKGROUND: The National Asthma Education Prevention Program's (NAEPP) Expert Panel Report 3 (EPR3) guidelines have stressed the need for environmental control measures for asthma, but there is limited evidence of their efficacy. OBJECTIVE: To examine the effectiveness of an in-home asthma intervention program for children and adults in Connecticut, we conducted a panel study to analyze quality-of-life indicators for asthmatic patients and the cost-benefit relationship in preventive care versus acute care. METHODS: The Asthma Indoor Reduction Strategies (AIRS) program was developed to reduce acute asthma episodes and improve asthma control through patient education and a home environmental assessment. Follow-up was conducted at 2-week, 3-month, and 6-month intervals. Measured quality-of-life indicators included number of unscheduled acute care visits, days absent from school/work due to asthma, times rescue inhaler used, and number of symptom-free days. Repeated measures analysis of variance (ANOVA) was used to determine whether significant differences exist in quality-of-life indicators at follow-up compared to that at the initial visit. Cost-benefit analysis was conducted by tabulating costs associated with physician office visits and emergency department (ED) visits due to asthma for children and adults separately. RESULTS: Twenty percent of participants in the program met the criteria for well-controlled asthma, 16% for not well-controlled asthma, and 64% for very poorly controlled asthma. At 6 months follow-up, the mean number of unscheduled acute care visits, days absent from school/work due to asthma, and times rescue inhaler used in the past week decreased by 87%, 82%, and 74%, respectively, whereas the mean number of symptom-free days increased by 27% compared to the initial visit. Furthermore, the percent of participants with very poorly controlled asthma decreased from 64% at initial visit to 13% at 6 months follow-up. All changes were statistically significant at p < 0.05. A net savings of $26,720 per 100 participants was estimated at 6 months follow-up due to decreases in unscheduled acute care visits for adults and children. CONCLUSION: Significant improvement in quality-of-life and decreases in healthcare resource utilization and costs were found after implementation of the AIRS program in Connecticut.