European Journal of Pediatrics

, Volume 178, Issue 2, pp 243–251 | Cite as

Determinants of low measles vaccination coverage in children living in an endemic area

  • Andrea Lo VecchioEmail author
  • Maria Donata Cambriglia
  • Maria Cristina Fedele
  • Francesca Wanda Basile
  • Fabrizia Chiatto
  • Michele Miraglia del Giudice
  • Alfredo Guarino
Original Article


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.

Conclusion: We reported inadequate measles immunization rate in Southern Italy, with lowest rates in children ≤ 2 years or with underlying conditions. Only a minority had true contraindications to vaccine uptake. Implementation strategies addressed to health-care professionals and families should focus on the reported determinants to increase measles vaccination coverage.

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.


Immunization Vaccine hesitancy MMR Italy 



Diphtheria/tetanus/pertussis/hepatitis B/polio/haemophilus influenzae type b




World Health Organization


Authors’ contributions

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.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

431_2018_3289_MOESM1_ESM.pdf (97 kb)
Supplemental table S1 STROBE checklist (PDF 96 kb)
431_2018_3289_MOESM2_ESM.pdf (23 kb)
Supplemental figure S2 The frequency of real contraindications (black) and false contraindications and other barriers (shaded in black) are reported according to each category. On the right column, different strategies to be addressed to health-care workers and general population are proposed to improve vaccination coverage


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Andrea Lo Vecchio
    • 1
    Email author
  • Maria Donata Cambriglia
    • 1
  • Maria Cristina Fedele
    • 2
  • Francesca Wanda Basile
    • 1
  • Fabrizia Chiatto
    • 1
  • Michele Miraglia del Giudice
    • 2
  • Alfredo Guarino
    • 1
  1. 1.Department of Translational Medical Sciences, Section of PediatricsUniversity of Naples Federico IINaplesItaly
  2. 2.Department of Woman, Child, and General and Specialized SurgeryUniversity of Campania Luigi VanvitelliNaplesItaly

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