In the early hours of 20 August 2026, a four-year-old girl died of diphtheria in Palermo, the first fatal case reported in Italy in more than three decades. According to reports, she and her three siblings had not been vaccinated because their parents believed that a vaccine had caused autism in a close relative. A vaccinated cousin of the same age, hospitalized with the same infection, had only mild disease. The girl had initially been assessed in an emergency department and discharged with a diagnosis of exudative tonsillitis before being readmitted as her condition deteriorated 1 . The death led to investigations into both the child's non-vaccination and the medical care she received. Cases such as this are often interpreted primarily as the consequence of individual parental decisions. That interpretation might not be wrong, but it is incomplete. This case did not result from lack of access to vaccination. It appears to have resulted from a belief that kept four children unvaccinated for years, in a country where diphtheria vaccination is legally mandatory. Individual decisions matter, but so do the responsibilities of public health institutions. The relevant question extends beyond why one family refused vaccination, to what immunization policies, and those who implement them, can do differently for all recommended vaccines.For the past two decades, vaccine hesitancy -the delay or refusal of vaccination despite the availability of services, as defined by WHO's Strategic Advisory Group of Experts (SAGE) (1) -has been the dominant framework for understanding declining vaccine uptake. It replaced a crude "informed versus misinformed" dichotomy with a continuum between unquestioning acceptance and outright refusal and showed that most vaccine-hesitant individuals are not opposed to vaccination but uncertain about it, delaying some vaccines while accepting others. Behavioral models such as WHO's Behavioral and Social Drivers of Vaccination (BeSD) (2) and the 5C model (3) have since enabled a more systematic understanding of the behavioral and social determinants of vaccination. Yet the claim that vaccines cause autism, originating from a fraudulent publication that was later retracted, continues to influence vaccination decisions more than two decades later (4,5), illustrating that debunking misinformation is not enough to restore confidence. A previous commentary in Public Health Reviews argued that Europe lacks a shared framework for tackling vaccine hesitancy at the individual or systemic level (6). We take the second view: the hesitancy framework explains how people decide, but says little about what health authorities owe families before that decision hardens into non-vaccination. Palermo illustrates that limitation. We do not know what opportunities for dialogue or intervention existed for this family, or whether any were missed. But the case raises a question that extends well beyond one household: whatever their institutional form, what responsibilities do immunization programs have to identify, engage and support families before non-vaccination results in serious illness? The quality of an immunization program should not be judged solely by the vaccination coverage it achieves, but also by its capacity to recognize these early signals and respond before preventable disease occurs.The COVID-19 pandemic made the consequences of declining vaccine confidence visible. In the United States alone, misinformation about COVID-19 vaccines has been estimated to have contributed to approximately 45,000 preventable deaths and more than US$2 billion in hospital costs during 2021 (7). The pandemic also showed that more communication does not translate into more confidence: health authorities communicated more than ever before, yet an infodemic, the overload of true and false information that makes reliable information hard to find, competed with that communication at an unprecedented scale. Addressing the infodemic became a public health priority, and WHO outlined this approach (8): monitoring public concerns, information environments and behavioral trends to detect declining confidence before it translates into falling vaccine uptake. The shift is from responding to misinformation once it has already spread, to detecting emerging concerns early enough to act through dialogue, evidence and appropriate public health measures.Vaccine confidence deserves the same standing in immunization programs as procurement, delivery, surveillance and coverage monitoring. It should not be treated as a communication add-on, summoned only once confidence starts to slip. It needs to be tracked and protected all the time. Coverage is essential, but it is a late indicator; confidence can erode for months or years before it shows up in the figures. Programs that also track the behavioral and social drivers of vaccination, engage with communities and invest in trust before crises arise are better placed to notice that erosion while there is still time to act.Treating confidence as a programmatic responsibility does not amount to state paternalism over individual choice. Vaccination against a transmissible disease is not a purely self-regarding decision: an unvaccinated child is not only at risk herself, but a possible link in a chain of transmission to infants too young to be vaccinated, to people who cannot be vaccinated for medical reasons, and to anyone whose protection depends on population-level immunity. That distinction between self-regarding and other-regarding behavior grounds vaccination as a public health measure rather than an individual choice. Countries differ widely in how they translate this responsibility into law. Some enforce active mandates: Italy expanded its list of compulsory childhood vaccines to ten in 2017, reinforcing existing obligations, including diphtheria, and adding new ones, with penalties for non-compliance (9), and France followed a similar path in 2018, extending its list further since 2 . Others make no vaccines compulsory, relying instead on recommendations issued by technical bodies and implemented through more or less decentralized structures, as in Germany 3 and Switzerland 4 , where confidence carries more of the weight in the absence of legal obligation. Still others retain vaccination laws that are rarely enforced, leaving uptake to depend almost entirely on public trust. Legal mandates and public confidence are complementary rather than interchangeable: a mandate can raise coverage for the vaccines it targets, but sustaining high uptake over time, and across the vaccines no mandate covers, depends on confidence (5). One condition for that confidence is the technical independence of the advisory bodies that issue immunization recommendations. In 2025, that independence came under political pressure in both Italy and the United States: an advisory panel was dissolved in Italy over contested appointments 5 and entirely replaced in the United States amid criticism of politicized decision-making (10).The diseases that vaccination prevents have not disappeared, and most cannot realistically be eradicated. They remain merely controlled, for as long as confidence in vaccines and in institutions holds. The first signs of faltering confidence rarely appear in emergency departments. They appear earlier, when institutions trade scientific independence for political convenience, and in communities whose concerns have never been asked about. Waiting for the visible return of disease to act is, almost always, arriving too late. That lesson will only grow more urgent as new and re-emerging infectious threats require rapid, sustained vaccine uptake. Palermo should be remembered not only as an individual tragedy, but as a reminder that protecting vaccine confidence is not a communication task delegated downstream. It is a core governance function of national immunization programs, and it deserves to be resourced, measured, and defended as one.Author contributions MT conceived, drafted, and approved the final version of this manuscript and takes full responsibility for its content.The author declares that no financial support was received for the research and/or publication of this article.The author declares no conflicts of interest.The author used Claude (Anthropic, Claude Opus 5) to assist with translation and English language editing. The author reviewed all content and takes full responsibility for the manuscript.
Tuberculosis (TB) remains a major global health concern, particularly in underdeveloped and developing countries. The Bacille Calmette–Guérin (BCG) vaccine, composed of live attenuated Mycobacterium Bovis, was first introduced for human use in 1921 to protect against tuberculosis. While the vaccine is considered safe, mild adverse effects such as pain, redness, and swelling at the injection site are relatively common. Less commonly recognized, but potentially more serious, adverse reactions include regional lymphadenitis, BCG-related osteitis, and disseminated BCG infection, particularly in individuals with compromised immune systems. This case report of BCG induced lymphadenitis in a 5- month-old male presented with swelling on left arm near deltoid region and left axillary area from 3 months along with discharging sinus present on neck and fever from 2 months.
Background and Aims: Human papillomavirus (HPV) vaccination is a critical intervention for cervical cancer prevention in Africa; however, program uptake and scale-up remain limited due to financing constraints. This scoping review mapped existing evidence on HPV vaccine financing in Africa, identifying prevailing funding mechanisms, cost estimates, delivery strategies, and challenges and opportunities for sustainable financing. Methods: Guided by the Arksey and O'Malley framework and PRISMA-ScR guidelines, we systematically searched nine electronic databases for peer-reviewed studies. Retrieved records were deduplicated and screened against eligibility criteria. Eligible studies underwent data extraction, followed by collation, summarization, and thematic synthesis. All costs were standardized to United States (US) Dollars and further adjusted to a common reference year (2025US) using the US Consumer Price Index (CPI-U) to enable comparison across study years. Results: Twenty-seven peer-reviewed studies were included. The review found heavy dependence on donor support, particularly from Gavi, with limited domestic co-financing across most countries. Per-dose costs ranged from US$0.27-US$19.76 (financial) and US$1.31-US$45.00 (economic) as reported, or US$0.32-US$26.50 and US$1.63-US$60.36 after adjustment to 2025 US; per fully immunized girl, costs ranged from US$6.68-US$40.03 and US$17.31-US$91.19 as reported, or US$8.31-US$53.69 and US$21.53-US$122.31 adjusted. Primary cost drivers included service delivery, personnel, and outreach to out-of-school girls. School-based delivery was more cost-effective in several contexts, and the single-dose schedule consistently showed lower cost with comparable efficacy, enhancing cost-effectiveness and reducing programmatic burden. Willingness to pay exists among private individuals, but out-of-pocket models remain inequitable. Conclusion: Donor funds, mainly Gavi, still drive HPV vaccination in most of Africa. The single-dose schedule cuts costs and logistics while remaining effective. For equitable, sustainable access, African countries must prioritize cost-effective vaccines, boost domestic funding, strengthen health systems, and adopt models that lessen reliance on external support.
Kafayat Aminu, Jimoh Amzat, Rita Amarachi Nwebo et al.
Pakistan is one of the ten countries with the least vaccinated children, and remains to face continued challenges, including endemic polio and periodic measles outbreaks. This study examines the regional disparities of basic vaccination coverage and the impact of socio-economic factors on its improvement between 2006 and 2018 by utilizing the data from the Pakistan Demographic and Health Surveys (PDHSs). The findings divulge significant regional disparities, with children in Sindh, Khyber Pakhtunkhwa (KP), and Balochistan being 18, 13.5, and 21.6 percentage points less likely, respectively, to be fully immunized as compared to children in Punjab. Higher household wealth correlates with increased immunization likelihood, and children of educated mothers are significantly more likely to be fully immunized. Moreover, male children are more likely to be fully immunized than female children, and antenatal care and institutional births further enhance vaccination rates. A nonlinear decomposition analysis shows a 20.2 percentage point increase in coverage during this period, with given factors explaining 45% of this rise. These results underscore the need for targeted interventions in underserved regions, socio-economic support for low-income families, educational initiatives for mothers, and enhanced antenatal care and institutional delivery services to improve nationwide vaccination rates.
Muhammad Irfan Malik, Muhammad Nadeem, Asad Ul Islam Khan
INTRODUCTION: Research shows that intranasal live attenuated influenza vaccine (LAIV) availability in addition to injectable inactivated influenza vaccine (IIV) is associated with higher influenza vaccination coverage rate (VCR). PEARL explored associations between LAIV availability and overall influenza vaccine uptake in children and adolescents. METHODS: PEARL was a cross-sectional study with ecological analysis using pooled country-level data from Northern Hemisphere countries with national recommendations for pediatric influenza vaccination (2024/25 season). Data sources included supra-national organizations and national public health institutes. LAIV availability was categorized as: none (IIV available); private (IIV available, LAIV accessible through the private market); or public (IIV available, LAIV offered via a publicly funded program). VCR was defined as the proportion of children and adolescents aged 2 to < 18 years receiving any influenza vaccine (LAIV/IIV) during the 2024/25 season. Beta regression assessed the association between LAIV availability and VCR, considering 27 covariates via two approaches: least absolute shrinkage and selection operator regression (Model 1); and literature-informed covariate selection (Model 2). Subanalyses assessed the association between LAIV availability (available versus none) and VCR, adjusting for vaccine funding structure (public: full, public: partial [funding restricted to specific age or high-risk groups], or private). RESULTS: Among 36 countries, 20 (55.6%) offered IIV and 16 (44.4%) offered LAIV and IIV. Median pediatric influenza VCR across all countries was 11.1%. VCR was higher in countries with publicly funded LAIV programs versus those offering only IIV in both analyses. In the subanalysis, the odds of influenza vaccination were higher in settings with public LAIV availability versus no LAIV availability (Model 1: odds ratio [OR] 2.66, 95% confidence interval [CI] 1.37-5.15; Model 2: OR 1.87, 95% CI 0.66-5.29). CONCLUSIONS: Higher pediatric influenza VCR was observed in settings with publicly funded access to LAIV. This positive association was directionally consistent regardless of vaccine funding structure.
Mirna Robert-Du Ry van Beest Holle, Sudhir Venkatesan, Joshua Enxing et al.
OBJECTIVES: Infant respiratory syncytial virus (RSV) prevention has moved from selective palivizumab prophylaxis toward broader protection through long-acting monoclonal antibodies and maternal vaccination. We examined how this research area evolved and whether original studies address evidence needed for implementation at scale. MATERIALS AND METHODS: We conducted a bibliometric analysis and evidence-gap mapping study of Web of Science Core Collection records from 1998 to 2025. The bibliometric corpus included 2004 publications; 1581 original articles underwent relevance screening and targeted audit, yielding 1227 studies for evidence-gap mapping. Analyses compared 1998-2022 with 2023-2025. A random sample of 150 articles was used to validate relevance screening. RESULTS: Publication output rose sharply after 2022, with 2023-2025 accounting for 35.0% of the bibliometric corpus. Earlier work centered on palivizumab, preterm infants, and hospitalization; recent studies increasingly addressed nirsevimab, maternal RSV vaccination, implementation, and vaccine candidates. Hospitalization outcomes, disease burden, monoclonal antibody strategies, and real-world effectiveness were well represented, whereas coverage/uptake, acceptance, equity, safety monitoring, economic evaluation, applicability to low- and middle-income countries, and coordination between maternal vaccination and infant monoclonal antibodies were less common. Validation showed 86.7% agreement (Cohen's kappa = 0.52). CONCLUSIONS: The literature has shifted toward broad infant RSV protection, but implementation-relevant evidence remains uneven. Comparative and program-level research is needed to determine how maternal vaccination and infant monoclonal antibody strategies can be implemented and coordinated across health systems while minimizing missed opportunities for protection.
BACKGROUND: Aboriginal and Torres Strait Islander peoples experience a greater burden of cervical cancer than other Australians. Vaccination can prevent diseases caused by human papillomavirus (HPV), but uptake remains inequitable. We aimed to understand barriers and enablers influencing the participation of Queensland Aboriginalmed and Torres Strait Islander adolescents in the school-based HPV vaccination program. METHODS: Using an Indigenist research approach and guided by a socio-ecological model for health promotion, Aboriginal and Torres Strait Islander voices were centred in this project. In 2020-2021 we conducted Yarns (a culturally appropriate qualitative method) with 65 Aboriginal and Torres Strait Islander adolescents and 20 parents from 10 diverse Queensland schools. Yarns addressed understandings of HPV and HPV vaccination, information and resources, vaccine consent, experience of vaccination, and suggestions for improvement. Thematic analysis using a codebook approach was conducted. RESULTS: The first major theme related to factors leading up to the vaccination clinic. Despite varying levels of knowledge and understanding of HPV and HPV vaccination, most adolescents and parents supported the idea of vaccinations to prevent diseases and benefit their health. Adolescents and parents reported difficulties completing and returning the consent form and wanted more accessible information and improved communication about the vaccine, delivered in culturally appropriate ways. The second major theme related to factors on the day of the vaccination clinic. Adolescents reported a need for privacy during vaccination, ways to manage heightened emotions triggered by the vaccination clinic, and the presence of trusted support people. Findings were contextualised within the COVID-19 pandemic and vaccination rollout, with the pandemic causing disruptions to the school program and the HPV vaccine perceived as more trustworthy than the then-new COVID-19 vaccines. CONCLUSIONS: We provide several recommendations to support Aboriginal and Torres Strait Islander adolescents to be vaccinated against HPV, such as flexible consent processes with assistance from Aboriginal and Torres Strait Islander support staff; availability of culturally safe educational materials for adolescents, parents and school staff; the presence of Aboriginal and Torres Strait Islander support staff at clinics, and adherence to optimal clinic set up and scheduling to improve adolescents' experience of vaccination. These recommendations can guide programmatic changes and interventions to increase HPV vaccination rates among Aboriginal and Torres Strait Islander adolescents, thereby advancing equity in cervical cancer outcomes.
Tamara Butler, Kate Anderson, Ami Morseu-Diop et al.
Liberia instituted a National Community Health Assistant Program (NCHAP) to increase primary healthcare access for residents living >5 km from health facilities. We evaluated the impact of this program on under-five mortality in rural Grand Bassa County as it was rolled out, between 2018 and 2022. The program was implemented in a stepped manner two districts at-a-time across Grand Bassa County from 2018 to 2022, allowing for a quasi-experimental observational stepped-wedge impact evaluation. We conducted a household census in 2022 to collect birth and death histories from all mothers in the program catchment area. We fitted mixed-effects Cox proportional hazards models to estimate the relative hazard of death among children <5 in the before- and under-intervention periods. We also compared data from the 2022 survey with a 2018 baseline household survey to estimate changes in care-seeking and healthcare service delivery coverage. We surveyed 22,315 female respondents about 32,743 children <5 who contributed person-time to the analysis. We found no difference in <5 mortality between the before- and under-intervention periods (unadjusted U5MR under intervention was higher at 62.0 versus 56.3 deaths per live births; adjusted hazard ratio 1.03 (95%CI 0.82-1.31). Care-seeking from a qualified healthcare provider for fever, diarrhea, or acute respiratory infection increased (27.0% to 53.7%; p < 0.001); and care-seeking decreased from drugstores (16.4% to 4.9%, p < 0.001) and black-market providers (42.4% to 22.7%, p < 0.001). Full vaccination among 12-23-month-olds decreased (16.2% in 2018 to 3.5% in 2022 (p < 0.001)) while facility-based delivery increased (41.0% to 57.1% (p < 0.001)). We detected no reduction in under-five mortality during initial implementation of the national CHA program in one Liberian county. Coverage of childhood treatment for high-priority conditions improved, and we observed a shift in care-seeking to trained providers. These results suggest potential program benefits, but additional interventions, some of which are already underway, will be needed to reduce under-five mortality.
Hawa I. Obaje, Emily E. White, Mardieh Dennis et al.
The first 1,000 days, from conception to a child's second birthday, shape maternal survival, newborn health and the course of early child development. Nurses and midwives deliver most of the care received in this period, yet evidence on their contribution is usually reported one stage at a time. This narrative review brings that evidence together across the whole continuum. PubMed/MEDLINE, Scopus, Web of Science, CINAHL, Embase, the Cochrane Library, WHO IRIS and UNICEF repositories were searched for English-language publications from January 2019 to June 2026, and current WHO guidance was consulted. Eighteen key studies were charted and synthesised thematically. Midwife continuity of care increased spontaneous vaginal birth and reduced caesarean and instrumental birth, although its effect on preterm birth was small or uncertain. Midwife-delivered bundles for postpartum haemorrhage, basic newborn resuscitation training, deferred cord clamping and immediate kangaroo mother care reduced severe morbidity or mortality in trials from low- and middle-income countries. Kangaroo mother care also lowered maternal depressive symptoms, and breastfeeding support reduced early cessation of exclusive breastfeeding. Parenting programmes improved early child development, whereas intensive nurse home visiting in one large trial did not change birth outcomes. Two-way mobile health communication increased antenatal attendance and skilled birth attendance. Three gaps remain: in coverage, in quality and in continuity between facility and community, with the second year of life the least studied. Closing them requires adequate nursing and midwifery staffing, competency-based education and services that follow the mother–child pair through all 1,000 days.
Somalia's escalating humanitarian financing crisis is exposing a neglected dimension of health-system vulnerability: aid volatility can itself become a determinant of primary health-care (PHC) failure. Recent funding contractions have disrupted hospitals, primary facilities, mobile teams, and nutrition services while drought, displacement, infectious-disease outbreaks, and undernutrition continue to intensify health needs. In a system heavily reliant on external financing, abrupt donor withdrawal can destabilise frontline staffing, essential medicines, referral pathways, surveillance, and continuity of care. These disruptions disproportionately threaten populations already experiencing structural disadvantage, particularly children, displaced communities, and households exposed to recurrent climate shocks. We argue that humanitarian financing should, therefore, be understood not only as emergency assistance but also as a critical determinant of health-system resilience and equity. Protecting essential PHC functions, strengthening government stewardship, establishing predictable transition financing, and investing in climate-resilient community health systems are essential to prevent financing shocks from becoming enduring public-health crises.
Fardowso Mohamed Harbi, Ilyas Abdullahi Khalif, Samar Yusuf Omar et al.
