In March 2012, the SAGE Working Group on Vaccine Hesitancy was convened to define the term "vaccine hesitancy", as well as to map the determinants of vaccine hesitancy and develop tools to measure and address the nature and scale of hesitancy in settings where it is becoming more evident. The definition of vaccine hesitancy and a matrix of determinants guided the development of a survey tool to assess the nature and scale of hesitancy issues. Additionally, vaccine hesitancy questions were piloted in the annual WHO-UNICEF joint reporting form, completed by National Immunization Managers globally. The objective of characterizing the nature and scale of vaccine hesitancy issues is to better inform the development of appropriate strategies and policies to address the concerns expressed, and to sustain confidence in vaccination. The Working Group developed a matrix of the determinants of vaccine hesitancy informed by a systematic review of peer reviewed and grey literature, and by the expertise of the working group. The matrix mapped the key factors influencing the decision to accept, delay or reject some or all vaccines under three categories: contextual, individual and group, and vaccine-specific. These categories framed the menu of survey questions presented in this paper to help diagnose and address vaccine hesitancy.

HighlightsVaccine hesitancy is a global problem that is complex and multilayered. Vaccine hesitancy is context, time, place and vaccine specific.Interviews with immunization managers were conducted to determine the breadth and perceived drivers of vaccine hesitancy at the countries’ level.Our study results, not unexpectedly, revealed a wide variation in the reported basis for vaccine hesitancy across countries.

Based on the concerns about vaccine hesitancy and its impact on vaccine uptake rates and the performance of national immunization programmes, the Strategic Advisory Group of Experts (SAGE) on Immunization Working Group on Vaccine Hesitancy [1], carried out a review, and proposed a set of recommendations directed to the public health community, to WHO and its partners, and to the World Health Organization (WHO) member states. The final recommendations issued by SAGE in October 2014 fall into three categories: (1) those focused on the need to increase the understanding of vaccine hesitancy, its determinants and the rapidly changing challenges it entails; (2) those focused on dealing with the structures and organizational capacity to decrease hesitancy and increase acceptance of vaccines at the global, national and local levels; (3) and those focused on the sharing of lessons learnt and effective practices from various countries and settings as well as the development, validation and implementation of new tools to address hesitancy.

Despite a wide array of safe and effective vaccines in use globally, with major impacts on health worldwide, the WHO Strategic Advisory Group of Experts (SAGE) on Immunization has been repeatedly confronted with reports of hesitancy towards accepting specific vaccines or vaccination programmes. This paper summarizes the rationale for a SAGE review of the issue of vaccine hesitancy, its impact and ways to address it, and the convening of a Vaccine Hesitancy Working Group in March 2012 to prepare for the SAGE review. It describes the methods used and mode of operations, and advances in the relatively new field of research on vaccine hesitancy. It further elaborates and references the work conducted, including a series of products, conclusions and recommendations that emerged from the SAGE review in October 2014.

IntroductionPersisting human papillomavirus (HPV) infections, especially with HPV high-risk types 16 or 18, are prerequisites for cervical precancer and cancer. At the end of 2006 a quadrivalent HPV-vaccine became available in Germany providing protection against the HPV-types 6, 11, 16, and 18. The primary vaccination series consists of 3 separate doses administered at 0, 2, and 6 mo. If an alternate vaccination schedule is necessary, the second dose should be administered at least one month after the first and the third at least 3 mo after the second dose. The primary vaccination series should be completed within a 1-y period, according to the German summary of product characteristics (SPC). In 2007, a bivalent vaccine was approved for immunisation against HPV-types 16 and 18. For this vaccine, the German SPC recommends a vaccination schedule of 0, 1, 6 mo. HPV vaccination is free of charge in Germany. In clinical trials, the HPV-vaccines demonstrated > 90% efficacy against HPV 16-and 18-related Purpose: since March 2007, the standing committee on Vaccination (sTIKO) recommends HpV vaccination for all 12-17 y-old females in Germany. In the absence of an immunization register, we aimed at assessing HpV-vaccination coverage and knowledge among students in Berlin, the largest city in Germany, to identify factors influencing HpV-vaccine uptake.Results: Between september and December 2010, 442 students completed the questionnaire (mean age 15.1; range 14-19). In total 281/442 (63.6%) students specified HpV correctly as a sexually transmitted infection. Of 238 participating girls, 161 (67.6%) provided their vaccination records. among these, 66 (41.0%) had received the recommended three HpVvaccine doses. Reasons for being HpV-unvaccinated were reported by 65 girls: Dissuasion from parents (40.2%), dissuasion from their physician (18.5%), and concerns about side-effects (30.8%) (multiple choices possible). The odds of being vaccinated increased with age [Odds Ratio (OR) 2.19, 95% confidence Interval (cI) 1.16, 4.15] and decreased with negative attitude toward vaccinations (OR = 0.33, 95% cI 0.13, 0.84).Methods: self-administered questionnaires were distributed to 10th grade school students in 14 participating schools in Berlin to assess socio-demographic characteristics, knowledge, and statements on vaccinations. Vaccination records were reviewed. Multivariable statistical methods were applied to identify independent predictors for HpV-vaccine uptake among female participants.Conclusions: HpV-vaccine uptake was low among school girls in Berlin. Both, physicians and parents were influential regarding their HpV-vaccination decision even though personal perceptions played an important role as well. school programs could be beneficial to improve knowledge related to HpV and vaccines, and to offer low-barrier access to HpV vaccination.Human papillomavirus vaccine uptake, knowledge and attitude among 10th grade students in Berlin, Germany, 2010 In Germany, a structured program for the evaluation and assessment of the impact...