Determinants of low measles vaccination coverage in children living in an endemic area
Measles outbreaks were recently reported in Europe due to low immunization rates. In this scenario, identifying the reasons of no vaccination is crucial to set up strategies to improve immunization rate. A cross-sectional study was conducted to investigate the determinants of missed vaccination in children living in Southern Italy, during the 2016 outbreak. A standardized face-to-face questionnaire was used to record demographic data, immunization status, and reasons for missed vaccination. A total of 1141 children (median age 86 months, male 47.2%) was enrolled, 77.8% of the children were adequately vaccinated for age, 6.3% were incompletely vaccinated for age, and 15.9% did not receive any vaccine dose. Vaccination rate and reasons for not vaccinating significantly varied according to age, with children ≤ 24 months showing the lowest rate (67.8%). Reasons for not vaccinating included fear for side effects (51%), presence of underlying chronic conditions (12.2%), skip scheduled appointment (12.2%), refusal of vaccination (10.3%), acute illnesses (7.2%), and allergy to eggs (4.6%). The presence of underlying condition was a risk factor for inadequate immunization (p < 0.0001). Only 4.7% of conditions were true contraindications to vaccine administration.
What is Known:
• Measles is a viral, highly communicable disease, preventable by vaccine.
• Measles elimination in Europe failed as demonstrated by outbreaks in several countries, due to low immunization rates.
What is New:
• Inadequate measles immunization rate due to false contraindications in Southern Italy, with lowest rates in children ≤ 2 years.
• The presence of underlying disease is a risk factor for inadequate immunization.
KeywordsImmunization Vaccine hesitancy MMR Italy
Diphtheria/tetanus/pertussis/hepatitis B/polio/haemophilus influenzae type b
World Health Organization
ALV and AG conceived the study.
ALV and MDC designed the study protocol and prepared the first draft of the survey.
AG revised and approved the survey before dissemination.
MDC, MCF, FC, and FWB administered the survey to families and caregivers.
MDC and MCF developed the database. ALV performed the statistical analysis and wrote the first draft of the manuscript. ALV and MDC produced tables and figures.
AG and MMDG provided substantial contribution to draft the paper and reviewed the final manuscript.
All authors gave their final approval of the version to be published and agree to be accountable for all aspects of the work.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
Informed consent was obtained from all individual participants included in the study.
- 1.American Academy of Pediatrics – RedBook Edition 2015Google Scholar
- 7.Center for Diseases control and prevention n.d. Traveler’s health: Measles in Italy. Available from: https://wwwnc.cdc.gov/travel/notices/watch/measles-italy
- 8.Centers for Disease Control and Prevention (CDC) (2003) Measles epidemic attributed to inadequate vaccination coverage--Campania, Italy, 2002. MMWR Morb Mortal Wkly Rep 52:1044–1047Google Scholar
- 9.Covolo L, Ceretti E, Passeri C, Boletti M, Gelatti U (2017) What arguments on vaccinations run through YouTube videos in Italy? A content analysis. Hum Vaccin Immunother 31:1–7Google Scholar
- 11.ECDC Surveillance and disease data. Monthly measles epidemiological updates. Available from: http://ecdc.europa.eu/en/healthtopics/measles/epidemiological_data/Pages/measles_surveillance_reports.aspx
- 12.Epicentro. Morbillo & Rosolia News: il bollettino della sorveglianza integrata morbillo-rosolia, Available from: http://www.epicentro.iss.it/problemi/morbillo/bollettino/RM_News_2016_34.pdf. (accessed 30 Oct 2018)
- 13.Epicentro. Available from: http://www.epicentro.iss.it/temi/vaccinazioni/dati_Ita.asp#morbillo (accessed 30 Oct 2018)
- 14.Filia A, Bella A, Rota M, Tavilla A, Magurano F, Baggieri M, Nicoletti L, Iannazzo S, Pompa M, Declich S (2013) Analysis of national measles surveillance data in Italy from October 2010 to December 2011 and priorities for reaching the 2015 measles elimination goal. Euro Surveill 18(20)Google Scholar
- 19.Grammens T, Maes V, Hutse V, Laisnez V, Schirvel C, Trémérie JM, Sabbe M (2016) Different measles outbreaks in Belgium, January to June 2016 - a challenge for public health. Euro Surveill 21(32)Google Scholar
- 23.Leask J, Chapman S, Hawe P, Burgess M (2006) What maintains parental support for vaccination when challenged by anti-vaccination messages? A qualitative study. Vaccine 24(49–50):7Google Scholar
- 25.Mankertz A, Mulders MN, Shulga S, Kremer JR, Brown KE, Santibanez S, Muller CP, Tikhonova N, Lipskaya G, Jankovic D, Khetsuriani N, Martin R, Gavrilin E (2011) Molecular genotyping and epidemiology of measles virus transmission in the World Health Organization European region, 2007-2009. J Infect Dis 204(Suppl 1):S335–S342CrossRefGoogle Scholar
- 27.McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS (2013) Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 62(RR-04):1–34Google Scholar
- 29.Vaccine Recommendations and Guidelines of the ACIP n.d. Contraindications and precautions updates. Available from: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html
- 30.World Health Organization (WHO). Renewed commitment to measles and rubella elimination and prevention of congenital rubella syndrome in the WHO European Region by 2015. Regional Committee for Europe. Sixtieth session. Moscow, 13–16 September 2010Google Scholar
- 31.World Health Organization (WHO). Surveillance guidelines for measles, rubella and congenital rubella syndrome in the WHO European region. Update December 2012. Available at: http://www.euro.who.int/__data/assets/pdf_file/0018/79020/e93035-2013.pdf
- 32.World Health Organization (WHO) (2012) Global measles and rubella strategic plan: 2012–2020. WHO, Geneva Available from: http://apps.who.int/iris/bitstream/10665/70254/1/WHO_IVB_10.02_eng.pdf. (accessed 30 Oct 2018)Google Scholar
- 33.World Health Organization (WHO). Measles. Fact sheet no 286. 2013. MRI report 2012. Available at: http://www.measlesrubellainitiative.org/wp-content/uploads/2013/07/MRI-2012-Annual-Report.pdf