Special Issue "Measure to Improve Vaccination Coverage In at Risk Categories: Pregnant Women, Healthcare Workers and Patients with Chronic Diseases"

A special issue of Vaccines (ISSN 2076-393X). This special issue belongs to the section "Clinical Immunology".

Deadline for manuscript submissions: closed (12 August 2022) | Viewed by 28111

Special Issue Editors

Department of Biomedical Sciences and Morphological and Functional Images (BIOMORF), University of Messina, 98124 Messina, Italy
Interests: communicable diseases and vaccination strategies; risk communication; non-communicable disease; public health; HCAIs
Special Issues, Collections and Topics in MDPI journals
Department of Biomedical Sciences, Dental Sciences and Morpho-Functional Images, University of Messina, 98125 Messina, Italy
Interests: vaccination coverage; vaccination strategies; healthcare-associated infections; hospital hygiene; flu
Special Issues, Collections and Topics in MDPI journals
Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, PV, Italy
Interests: public health; epidemiology; prevention; vaccines; immunisation policies; information and communication technology, digital health
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

In recent years, a phenomenon known as "vaccine hesitancy" has spread throughout the world, even among healthcare workers, determining a reduction in vaccination coverage, although vaccination is widely considered to be an efficacious and cost-effective health technology.

Although some data about vaccination coverage are not systematically available for some at-risk categories, i.e., pregnant women, healthcare workers and patients with chronic diseases, the international literature shows a poor adhesion.

Manuscripts reporting on vaccines administered to pregnant women, at-risk patients (with chronic diseases such as, i.e., HIV or kidney failure, or other risk factors) and healthcare workers and on strategies adopted to promote vaccination adherence by these categories are welcomed for this Special Issue.

This Special Issue encourages the submission of original articles, systematic reviews, meta-analyses, short communications, and other types of articles that describe measures and strategies to improve vaccination coverage in these categories that could be adapted in other settings and countries.

Dr. Cristina Genovese
Prof. Squeri Raffaele
Dr. Claudio Costantino
Prof. Anna Odone
Guest Editors

Manuscript Submission Information

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Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2700 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • vaccination coverage
  • improvement
  • at-risk populations
  • pregnancy
  • healthcare workers

Published Papers (12 papers)

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Research

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Article
Vaccine Resistance and Hesitancy among Older Adults Who Live Alone or Only with an Older Partner in Community in the Early Stage of the Fifth Wave of COVID-19 in Hong Kong
Vaccines 2022, 10(7), 1118; https://doi.org/10.3390/vaccines10071118 - 13 Jul 2022
Cited by 7 | Viewed by 2377
Abstract
Vaccination is an effective way in providing protection against COVID-19 infection and severe outcomes. However, vaccine resistance and hesitancy are a great concern among vulnerable populations including older adults who live alone or only with an older partner. This study examined their vaccination [...] Read more.
Vaccination is an effective way in providing protection against COVID-19 infection and severe outcomes. However, vaccine resistance and hesitancy are a great concern among vulnerable populations including older adults who live alone or only with an older partner. This study examined their vaccination status and reasons and associated factors of vaccine resistance and hesitancy. A cross-sectional study was conducted among older adults living alone or only with an older partner in communities in Hong Kong. Participants were interviewed between October 2021 and February 2022. Logistic regression analyses were employed to examine factors associated with vaccine resistance and hesitancy. Of the 2109 included participants, the mean age was 79.3 years (SD 7.6), 1460 (69.2%) were female, 1334 (63.3%) lived alone, and 1621 (76.9%) were receiving social security support. The vaccine uptake, non-uptake (i.e., resistance), and hesitancy rates were 50.1%, 34.4%, and 15.5%, respectively. The top four reasons for vaccine resistance and hesitancy were “Not feeling in good health” (27%), “Worry about vaccine side effects” (18%), “Feeling no need” (10%), and “Lack of recommendation from doctors” (9%). Vaccine resistance and hesitancy was significantly associated with older age, living alone, more chronic conditions, fewer types of social media use, and lower self-rated health status. Similar associations can be observed in their separate analysis for vaccine resistance and vaccine hesitancy, and ever hospital admission over the past 6 months was additionally related to vaccine hesitancy. Older people who live alone or only with an older partner had a low vaccination rate. Poor health or worry about vaccine side effects were the most common reasons for their vaccine resistance and hesitancy. Actions are greatly needed to improve the uptake rate among this vulnerable population, especially those who were older, have poorer health, and use less social media. Full article
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Article
Seroprevalence against Diphtheria in Pregnant Women and Newborns in Colombia: New Arguments to Promote Maternal Immunization
Vaccines 2022, 10(3), 458; https://doi.org/10.3390/vaccines10030458 - 17 Mar 2022
Viewed by 1547
Abstract
The tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine is recommended during pregnancy for neonatal protection against pertussis, although little is known of the protection it provides against diphtheria. The work used a cross-sectional design to estimate seroprevalence against diphtheria in [...] Read more.
The tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine is recommended during pregnancy for neonatal protection against pertussis, although little is known of the protection it provides against diphtheria. The work used a cross-sectional design to estimate seroprevalence against diphtheria in 805 pregnant women with ≥37 gestation weeks and their newborns whose deliveries were attended in eight hospitals randomly chosen from a subregion of Antioquia, Colombia and to explore factors related with maternal protection. Levels of IgG antibodies were determined by using a commercial enzyme-linked immunosorbent assay test. Placental transfer of antibodies and crude and adjusted prevalence ratio (aPR) were analyzed to describe factors related with maternal protection against diphtheria. Protection against diphtheria was observed in 91.7% (95% CI 90.3–93.0) of the pregnant women and 93.1% (95% CI 91.7–94.4) of newborns, whose antibody levels were positively correlated (Spearman’s r = 0.769; p = 0.000). Maternal protection could be influenced by having been vaccinated during the current pregnancy (aPR 0.85, 95% CI: 0.82–0.93). The protective effect of vaccination during pregnancy and the efficiency of maternal antibody transfers were detected. Public health efforts should focus on increasing Tdap vaccination during each pregnancy to protect mothers and newborns against diphtheria. Full article
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Article
A Knowledge, Attitude, and Perception Study on Flu and COVID-19 Vaccination during the COVID-19 Pandemic: Multicentric Italian Survey Insights
Vaccines 2022, 10(2), 142; https://doi.org/10.3390/vaccines10020142 - 19 Jan 2022
Cited by 12 | Viewed by 2230
Abstract
In January 2020, Chinese health authorities identified a novel coronavirus strain never before isolated in humans. It quickly spread across the world, and was eventually declared a pandemic, leading to about 310 million confirmed cases and to 5,497,113 deaths (data as of 11 [...] Read more.
In January 2020, Chinese health authorities identified a novel coronavirus strain never before isolated in humans. It quickly spread across the world, and was eventually declared a pandemic, leading to about 310 million confirmed cases and to 5,497,113 deaths (data as of 11 January 2022). Influenza viruses affect millions of people during cold seasons, with high impacts, in terms of mortality and morbidity. Patients with comorbidities are at a higher risk of acquiring severe problems due to COVID-19 and the flu—infections that could impact their underlying clinical conditions. In the present study, knowledge, attitudes, and opinions of the general population regarding COVID-19 and influenza immunization were evaluated. A multicenter, web-based, cross-sectional study was conducted between 10 February and 12 July 2020, during the first wave of SARS-CoV-2 infections among the general population in Italy. A sample of 4116 questionnaires was collected at the end of the study period. Overall, 17.5% of respondents stated that it was unlikely that they would accept a future COVID-19 vaccine (n = 720). Reasons behind vaccine refusal/indecision were mainly a lack of trust in the vaccine (41.1%), the fear of side effects (23.4%), or a lack of perception of susceptibility to the disease (17.1%). More than 50% (53.8%; n = 2214) of the sample participants were willing to receive flu vaccinations in the forthcoming vaccination campaign, but only 28.2% of cases had received it at least once in the previous five seasons. A higher knowledge score about SARS-CoV-2/COVID-19 and at least one flu vaccination during previous influenza seasons were significantly associated with the intention to be vaccinated against COVID-19 and influenza. The continuous study of factors, determining vaccination acceptance and hesitancy, is fundamental in the current context, in regard to improve vaccination confidence and adherence rates against vaccine preventable diseases. Full article
Article
Using Google Trends to Predict COVID-19 Vaccinations and Monitor Search Behaviours about Vaccines: A Retrospective Analysis of Italian Data
Vaccines 2022, 10(1), 119; https://doi.org/10.3390/vaccines10010119 - 14 Jan 2022
Cited by 11 | Viewed by 2041
Abstract
Google Trends data are an efficient source for analysing internet search behaviour and providing valuable insights into community dynamics and health-related problems. In this article, we aimed to evaluate if Google Trends data could help monitor the COVID-19 vaccination trend over time and [...] Read more.
Google Trends data are an efficient source for analysing internet search behaviour and providing valuable insights into community dynamics and health-related problems. In this article, we aimed to evaluate if Google Trends data could help monitor the COVID-19 vaccination trend over time and if the introduction of COVID-19 vaccines modified the interest of pregnant women in vaccination. Data related to Google internet searches and the number of vaccine doses administered in Italy were used. We found moderate to strong correlations between search volumes of vaccine-related terms and the number of vaccines administered. In particular, a model based on Google Trends with a 3-week lag showed the best performance in fitting the number of COVID-19 vaccinations over time. We also observed that the introduction of COVID-19 vaccines affected the search interest for the argument “vaccination in pregnancy” both quantitatively and qualitatively. There was a significant increase in the search interest after the launch of the COVID-19 vaccination campaign in Italy. Qualitative analysis suggested that this increase was probably due to concerns about COVID-19 vaccines. Thus, our study suggests the benefits of using Google Trends data to predict the number of COVID-19 vaccine doses administered, and to monitor feelings about vaccination. Full article
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Article
Educational Interventions on Pregnancy Vaccinations during Childbirth Classes Improves Vaccine Coverages among Pregnant Women in Palermo’s Province
Vaccines 2021, 9(12), 1455; https://doi.org/10.3390/vaccines9121455 - 08 Dec 2021
Cited by 11 | Viewed by 2075
Abstract
Maternal immunization is considered the best intervention in order to prevent influenza infection of pregnant women and influenza and pertussis infection of newborns. Despite the existing recommendations, vaccination coverage rates in Italy remain very low. Starting from August 2018, maternal immunization against influenza [...] Read more.
Maternal immunization is considered the best intervention in order to prevent influenza infection of pregnant women and influenza and pertussis infection of newborns. Despite the existing recommendations, vaccination coverage rates in Italy remain very low. Starting from August 2018, maternal immunization against influenza and diphtheria-tetanus-pertussis were strongly recommended by the Italian Ministry of Health. We conducted a cross sectional study to estimate the effectiveness of an educational intervention, conducted during childbirth classes in three general hospitals in the Palermo metropolitan area, Italy, on vaccination adherence during pregnancy. To this end, a questionnaire on knowledge, attitudes, and immunization practices was structured and self-administered to a sample of pregnant women attending childbirth classes. Then, an educational intervention on maternal immunization, followed by a counseling, was conducted by a Public Health medical doctor. After 30 days following the interventions, the adherence to the recommended vaccinations (influenza and pertussis) was evaluated. At the end of the study 326 women were enrolled and 201 responded to the follow-up survey. After the intervention, among the responding pregnant women 47.8% received influenza vaccination (+44.8%), 57.7% diphtheria-tetanus-pertussis vaccination (+50.7%) and 64.2% both the recommended vaccinations (+54.8%). A significant association was found between pregnant women that received at least one vaccination during pregnancy and higher educational level (graduation degree/master’s degree), employment status (employed part/full-time) and influenza vaccination adherence during past seasons (at least one during last five years). The implementation of vaccination educational interventions, including counseling by healthcare professionals (HCPs), on maternal immunization during childbirth courses improved considerably the vaccination adherence during pregnancy. Full article
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Communication
COVID-19 Vaccine Acceptance among Liver Transplant Recipients
Vaccines 2021, 9(11), 1314; https://doi.org/10.3390/vaccines9111314 - 11 Nov 2021
Cited by 16 | Viewed by 1911
Abstract
(1) Background: COVID-19 vaccination hesitancy is a threat for fragile patients. We aimed to evaluate COVID-19 vaccination hesitancy and its reasons in a population of liver transplant (LT) recipients. (2) Methods: In February 2021, a questionnaire on COVID-19 vaccines was sent to LT [...] Read more.
(1) Background: COVID-19 vaccination hesitancy is a threat for fragile patients. We aimed to evaluate COVID-19 vaccination hesitancy and its reasons in a population of liver transplant (LT) recipients. (2) Methods: In February 2021, a questionnaire on COVID-19 vaccines was sent to LT patients followed at our liver transplant outpatient clinic in Milan, Italy. Sociodemographic and clinical characteristics were recorded. Patients were defined as willing, hesitant, or refusing and their reasons were investigated. Associations between baseline characteristics and willingness were evaluated. Since March 2021, when the COVID-19 vaccines became available for LT candidates and recipients in Italy, the entire cohort of LT recipients was contacted by phone and called for vaccination, and the rate of refusals recorded. (3) Results: The web-based survey was sent to 583 patients, of whom 190 responded (response rate of 32.6%). Among the respondents to the specific question about hesitancy (184), 157 (85.3%) were willing to be vaccinated against COVID-19, while 27 (14.7%) were hesitant. Among the hesitant, three were totally refusing, for a refusal rate of 1.6%. Thirteen hesitant patients (48.1%) answered that their COVID-19 vaccination hesitancy was influenced by being a transplant recipient. The fear of adverse effects was the main reason for refusal (81.5%). Of the 711 LT patients followed at our center, 668 got fully vaccinated, while 43 (6.1%) of them refused the scheduled vaccination. (4) Conclusions: Most patients accepted COVID-19 vaccines, although 6.1% refused the vaccine. Since it is crucial to achieve adequate vaccination of LT patients, it is very important to identify the reasons influencing COVID-19 vaccination hesitancy so that appropriate and targeted communication strategies can be established and specific vaccination campaigns further implemented. Full article
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Article
Descriptive Observational Study of Tdap Vaccination Adhesion in Pregnant Women in the Florentine Area (Tuscany, Italy) in 2019 and 2020
Vaccines 2021, 9(9), 955; https://doi.org/10.3390/vaccines9090955 - 26 Aug 2021
Cited by 3 | Viewed by 1501
Abstract
Background: Tdap (Tetanus-Diphtheria-acellular Pertussis) vaccination is nowadays a worldwide-recommended practice to immunize pregnant women. The vaccine administration at the third trimester of pregnancy (as recommended by the WHO) would ensure antibody protection to both the mother and the newborn and has contributed [...] Read more.
Background: Tdap (Tetanus-Diphtheria-acellular Pertussis) vaccination is nowadays a worldwide-recommended practice to immunize pregnant women. The vaccine administration at the third trimester of pregnancy (as recommended by the WHO) would ensure antibody protection to both the mother and the newborn and has contributed to the significant drop of pertussis cases in infants. The aim of this observational study was to describe for the first time the socio-demographic characteristics and determinants of Tdap vaccination adhesion of pregnant women in the Florentine area. Methods: Information about parents’ vaccination status, their citizenship, employment type and mothers’ previous pregnancies and/or abortions were collected at the time of birth through the assistance birth certificates (CedAP) both for the years 2019 and 2020. This archive and the regional SISPC (Collective Prevention Healthcare Information System) linked using an anonymous unique personal identifier to retrieve the mother’s vaccination status. Results: We found an overall Tdap vaccination adhesion of 43% in 2019 and 47.3% in 2020. Several socio-demographic parameters would determine an increased vaccination adhesion, including parents’ geographical origin, mothers’ age and educational background, as well as the number of previous deliveries, abortions or voluntary termination of pregnancy. Conclusions: Since not much data are available on this topic in Italy, this study may constitute the baseline information for Tdap vaccination adhesion in pregnant women in the Florentine area (Italy). Thus, future successful vaccination strategies may be designed accordingly. Full article
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Article
Type 1 Diabetes Patients’ Practice, Knowledge and Attitudes towards Influenza Immunization
Vaccines 2021, 9(7), 707; https://doi.org/10.3390/vaccines9070707 - 29 Jun 2021
Cited by 4 | Viewed by 1507
Abstract
Diabetic patients are at higher risk of developing infectious diseases and severe complications, compared to the general population. Almost no data is available in the literature on influenza immunization in people with type 1 diabetes mellitus (T1DM). As part of a broader project [...] Read more.
Diabetic patients are at higher risk of developing infectious diseases and severe complications, compared to the general population. Almost no data is available in the literature on influenza immunization in people with type 1 diabetes mellitus (T1DM). As part of a broader project on immunization in diabetic patients, we conducted a cross-sectional study to: (i) report on seasonal influenza coverage rates in T1DM patients, (ii) explore knowledge, attitudes, and practices (KAPs) towards seasonal influenza in this population, and (iii) identify factors associated with vaccine uptake, including the role of family doctors and diabetologists. A survey was administered to 251 T1DM patients attending the Diabetes Clinic at San Raffaele Research Hospital in Milan, Italy and individual-level coverage data were retrieved from immunization registries. Self-reported seasonal influenza immunization coverage was 36%, which decreased to 21.7% when considering regional immunization registries, far below coverage target of 75%. More than a third (36.2%) of T1DM patients were classified as pro-vaccine, 30.7% as hesitant, 17.9% as uninformed, and 15.1% as anti-vaccine. Diabetologists resulted to be the most trusted source of information on vaccines’ benefits and risks (85.3%) and should be more actively involved in preventive interventions. Our study highlights the importance of developing tailored vaccination campaigns for people with diabetes, including hospital-based programs involving diabetes specialists. Full article
Article
The Gender Impact Assessment among Healthcare Workers in the SARS-CoV-2 Vaccination—An Analysis of Serological Response and Side Effects
Vaccines 2021, 9(5), 522; https://doi.org/10.3390/vaccines9050522 - 18 May 2021
Cited by 45 | Viewed by 3399
Abstract
Healthcare professionals are considered to be at high risk of exposure and spread of SARS-CoV-2, and have therefore been considered a priority group in COVID-19 vaccination campaign strategies. However, it must be assumed that the immune response is influenced by numerous factors, including [...] Read more.
Healthcare professionals are considered to be at high risk of exposure and spread of SARS-CoV-2, and have therefore been considered a priority group in COVID-19 vaccination campaign strategies. However, it must be assumed that the immune response is influenced by numerous factors, including sex and gender. The analysis of these factors is an impact element for stratifying the population and targeting the vaccination strategy. Therefore, a large cohort of healthcare workers participating in the Italian vaccination campaign against SARS-CoV-2 has been studied to establish the impact of sex and gender on vaccination coverage using the Gender Impact Assessment approach. This study shows a significant difference in the antibody titers among different age and sex groups, with a clear decreasing trend in antibody titers in the older age groups. Overall, the serological values were significantly higher in females; the reported side effects are more frequent in females than in males. Therefore, disaggregated data point out how the evaluation of gender factors could be essential in COVID-19 vaccination strategies. On this biomedical and social basis, suggestions are provided to improve the SARS-CoV-2 vaccination campaign in healthcare professionals. Still, they could be adapted to other categories and contexts. Full article
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Article
COVID-19 Vaccine: A Survey of Hesitancy in Patients with Celiac Disease
Vaccines 2021, 9(5), 511; https://doi.org/10.3390/vaccines9050511 - 16 May 2021
Cited by 24 | Viewed by 3798
Abstract
(1) Background: COVID-19 vaccination campaigns offer the best hope of controlling the pandemic. However, the fast production of COVID-19 vaccines has caused concern among the general public regarding their safety and efficacy. In particular, patients with chronic illnesses, such as celiac disease (CD), [...] Read more.
(1) Background: COVID-19 vaccination campaigns offer the best hope of controlling the pandemic. However, the fast production of COVID-19 vaccines has caused concern among the general public regarding their safety and efficacy. In particular, patients with chronic illnesses, such as celiac disease (CD), may be more fearful. Information on vaccine hesitancy plays a pivotal role in the development of an efficient vaccination campaign. In our study, we aimed to evaluate COVID-19 vaccine hesitancy among Italian CD patients. (2) Methods: an anonymous questionnaire was sent to CD patients followed at our tertiary referral center for CD in Milan, Italy. Patients were defined as willing, hesitant and refusing. We evaluated the reasons for hesitancy/refusal and the possible determinants, calculating crude and adjusted odds ratios [AdjORs] with 95% confidence intervals [CIs]. (3) Results: the questionnaire was sent to 346 patients with a response rate of 29.8%. Twenty-six (25.2%) of the 103 respondents were hesitant, with a total refusal rate of 4.8%. The main reason was fear of adverse events related to vaccination (68.2%). Among hesitant patients, 23% declared that their opinion was influenced by their CD. The determinants positively influencing willingness to be vaccinated against COVID-19 were adherence to a GFD, perception of good knowledge about COVID-19 and its vaccines, and a positive attitude to previous vaccines (AdjOR 12.71, 95% CI 1.82–88.58, AdjOR 6.50, 95% CI 1.44–29.22, AdjOR 0.70, 95% CI 0.11–4.34, respectively). (4) Conclusions: CD patients should be vaccinated against COVID-19 and a specific campaign to address the determinants of hesitancy should be developed. Full article
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Article
Attitudes and Perception of Healthcare Workers Concerning Influenza Vaccination during the 2019/2020 Season: A Survey of Sicilian University Hospitals
Vaccines 2020, 8(4), 686; https://doi.org/10.3390/vaccines8040686 - 16 Nov 2020
Cited by 18 | Viewed by 2299
Abstract
Influenza is an infectious disease with a high impact on the population in terms of morbidity and mortality, but despite International and European guidelines, vaccination coverage rates among healthcare workers (HCWs) remain very low. The aim of the present study was to evaluate [...] Read more.
Influenza is an infectious disease with a high impact on the population in terms of morbidity and mortality, but despite International and European guidelines, vaccination coverage rates among healthcare workers (HCWs) remain very low. The aim of the present study was to evaluate influenza vaccination adherence in the three Sicilian University Hospitals of Catania, Messina, and Palermo and to understand the attitudes and perceptions of vaccinated healthcare workers and the main reasons for vaccination refusal. A cross-sectional survey through a self-administered questionnaire was conducted during the 2019/2020 influenza season. Overall, 2356 vaccinated healthcare workers answered the questionnaire. The main reason reported for influenza vaccination adherence during the 2019/2020 season was to protect patients. Higher self-perceived risk of contracting influenza and a positive attitude to recommending vaccination to patients were significantly associated with influenza vaccination adherence during the last five seasons via multivariable analysis. Fear of an adverse reaction was the main reason for influenza vaccine refusal. In accordance with these findings, Public Health institutions should develop and tailor formative and informative campaigns to reduce principal barriers to the immunization process and promote influenza vaccination adherence among HCWs. Full article
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Review

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Review
Insight into Prevention of Neisseria Gonorrhoeae: A Short Review
Vaccines 2022, 10(11), 1949; https://doi.org/10.3390/vaccines10111949 - 18 Nov 2022
Viewed by 1758
Abstract
Neisseria gonorrhoeae (gonococcus) and Neisseria meningitidis (meningococcus) are important global pathogens which cause the sexually transmitted diseases gonorrhea and meningitis, respectively, as well as sepsis. We prepared a review according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA), with the [...] Read more.
Neisseria gonorrhoeae (gonococcus) and Neisseria meningitidis (meningococcus) are important global pathogens which cause the sexually transmitted diseases gonorrhea and meningitis, respectively, as well as sepsis. We prepared a review according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA), with the aims of (a) evaluating the data on the MenB vaccination as protection against sexually transmitted infections by N. gonorrhoeae and (b) to briefly comment on the data of ongoing studies of new vaccines. We evaluated existing evidence on the effect of 4CMenB, a multi-component vaccine, on invasive diseases caused by different meningococcal serogroups and on gonorrhea. Non-B meningococcal serogroups showed that the 4CMenB vaccine could potentially offer some level of protection against non-B meningococcal serogroups and N. gonorrhoeae. The assessment of the potential protection conferred by 4CMenB is further challenged by the fact that further studies are still needed to fully understand natural immune responses against gonococcal infections. A further limitation could be the potential differences between the protection mechanisms against N. gonorrhoeae, which causes local infections, and the protection mechanisms against N. meningitidis, which causes systemic infections. Full article
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