key: cord-1039142-v0x7v9ig
authors: Katharina Schmid-Küpke, Nora; Matysiak-Klose, Dorothea; Siedler, Anette; Felgendreff, Lisa; Wieler, Lothar; Thaiss, Heidrun M.; Betsch, Cornelia
title: Cancelled routine vaccination appointments due to COVID-19 pandemic in Germany
date: 2021-04-01
journal: Vaccine X
DOI: 10.1016/j.jvacx.2021.100094
sha: cc7571caff8d5b32422d03e6b4c78159360c95e6
doc_id: 1039142
cord_uid: v0x7v9ig

Pandemic measures to mitigate the outbreak of SARS-CoV-2 in Germany led to cancellations of routine vaccination appointments for both adults and children. Survey data indicate that, with easing pandemic restrictions, many cancelled appointments were rescheduled or caught up. Nevertheless, 40% of cancelled appointments were still not rescheduled and were primarily cancelled by patients. Therefore, doctors should regularly remind patients of vaccinations and use every visit to improve their vaccination statuses.

done preparatory to the lockdown, childhood vaccinations need to be done on time and in practice. The German Standing Committee on Vaccination (STIKO) stated in April 2020 that, even in the pandemic, all recommended vaccinations should be carried out at the recommended age ( Figure 1 ) [4] . Protection is particularly important for immunocompromised persons or persons with other health risk factors. In particular, the recommended vaccinations in the first two years of life should be started in a timely manner and completed as early as possible. Moreover, individuals aged 60 years and older should receive vaccinations against pneumococci, shingles, and influenza [4] . The Federal Institution for Prevention and Health Promotion also published a press release on timely vaccinations during the pandemic, especially targeting childhood vaccinations [5] . To emphasize the importance of immunization services during the COVID-19 pandemic and to ensure safe vaccinations, the World Health Organization's Regional Office for Europe (WHO/Europe) published comprehensive guidelines in March 2020 [6] . Associations of German paediatricians repeatedly published statements pleading for the safe maintenance of vaccination services and early preventive medical check-ups for babies during the pandemic [1, 7] . In this situation of recurring warnings not to overburden the health system and encouragements to receive routine vaccinations, we aimed to assess the extent of cancelled vaccinations in Germany for children and adults at different points in time. We also examined whether cancellations depended on factors associated with vaccine hesitancy [8] . Finally, we investigated the efforts made to catch patients up on vaccinations.

Data were collected within three waves (waves 7, 9, and 14) of COSMO, a serial crosssectional survey monitoring public perceptions of risk, trust, knowledge, and misinformation on COVID-19 measures. Since March 3, 2020, about 1,000 participants constituted a weekly (since June, fortnightly) online quota-representative sample, mirroring Germany's age by gender distribution, as well as federal states. Results of COSMO are used to inform the government, journalists, and health organizations of the psychosocial COVID-19 situation in Germany and to help derive direct recommendations for action and implementation [9].

The first data collection on 4/14/20 assessed self-reported vaccination behaviours and vaccinations' psychological antecedents, such as trust in the safety and effectiveness of vaccines (confidence) or the willingness to protect others by one's own vaccination (collective responsibility). A subsample of adults with children under the age of 18 provided information on their children's vaccinations, as well. Self-reported behaviour was also assessed in the second data collection on 4/28/20. The second and third data collections on 6/9/20, also focused on the question of whether cancelled vaccination appointments were caught up. Table 1 presents an overview of all variables reported, including sample items, answer formats, and the date of data collection. The original data and syntax of the following analyses are provided at https://osf.io/av9wf/?view_only=1d14e70394eb415d8e240c6743803402 [10, 11, 12].

[ Table 1 near here] [ Table 2 near here]

The second data collection (4/28/20) revealed that, for adults, as many appointments were cancelled as before (53/123 = 43.09%). The most common reason for cancellation remained the pandemic situation (43/53 = 81.13%). In contrast to the previous data collection, where appointments were more often cancelled by physicians, appointments were now more frequently cancelled by patients (24/43 = 55.81%) than physicians (19/43 = 44.19%). For children, the overall proportion of cancelled appointments decreased. A higher percentage of the initially planned vaccination appointments took place (43/57 = 75.44%), while the reason most frequently given for cancellation remained the pandemic situation (12/14 = 85.71%). One third of the vaccination appointments for children were cancelled by the physician (4/12 = 33.33%) and two thirds by parents (8/12 = 66.66%).

In June 2020, the data collection revealed that more than half of the vaccination appointments took place for adults (73/135 = 54.07%), as well as for children (48/82 = 58.54%), although many appointments were still cancelled.

For the first data collection in April 2020, we explored the association between factors predicting vaccine hesitancy and patients' decisions to cancel vaccination appointments for themselves or their children. Of all potential psychological antecedents (confidence, constraints, complacency, calculation, and collective responsibility) [8], only confidence was associated with cancelling appointments. Figure 2 shows the number of vaccination appointments cancelled for adults, by patients (dotted) or physicians (striped), depending on their confidence in vaccinations (high vs. low, separated by a median split). While cancellations by the physician did not depend on the patient's confidence level, patients with low confidence cancelled appointments significantly more often than patients with high confidence in vaccinations (Chi-square(1) = 4.2, p = 0.040, n = 42). For children's vaccination appointments, there was no statistical association with any of the psychological antecedents.

[ Figure 2 near here]

In data collections on 4/28/20 and 6/9/20, we asked whether there was a catch-up 

Like in many other countries, Germany's vaccination appointments were postponed during the SARS-CoV-2 pandemic, and this trend has likely not stopped completely.

Appointment cancellations affected both adults' and children's vaccinations. Low confidence in vaccination [8] was associated with more frequent cancellations by the patients, while there was no association to any other psychological antecedent of vaccination. While we assume that most cancellations were pandemic-driven, rather than being deliberate decisions against vaccination due to a critical attitude towards vaccinations, the uncertainty of service delivery and safety around the process of getting vaccinated may have served as an excuse for those who have been unsure of vaccinations in the first place. Active service delivery conveying confidence, both in the value of vaccination during a pandemic and the practical management of infection risks in the medical practice, seems to be especially important to reach those with weak intentions to vaccinate. For people who might suffer from increasing anxiety disorders due to the pandemic and therefore avoid crowded places like medical practices, or whose excessive media consumption could have increase COVID-19 specific anxiety disorders, actively communicating confidence could also be a good support [13, 14] . 

Maintenance of vaccination and screening in the current SARS-CoV-2 pandemic

Early impact of the coronavirus disease (COVID-19) pandemic and physical distancing measures on routine childhood vaccinations in England

Decline in child vaccination coverage during the COVID-19 pandemic-Michigan Care Improvement Registry

Statement of the German Standing Committee on Vaccination: Carrying out recommended vaccinations during the COVID-19 pandemic

Federal Institution for Prevention and Health Promotion: European Immunization Week 2020

Guidance on routine immunization services during COVID-19 pandemic in the WHO European Region

pandemic: a cross-sectional study in Germany

Associations between COVID-19 related media consumption and symptoms of anxiety, depression and COVID-19 related fear in the general population in Germany

European Archives of Psychiatry and Clinical Neuroscience

Protection against infection -Attitudes, knowledge and behavior of adults and parents towards vaccinations. BZgA study report. Cologne: Federal Institution for Prevention and Health Promotion

Writing -Original draft preparation, Writing -Reviewing and Editing. Dorothea Matysiak-Klose: Formal Analysis, Writing -Reviewing and Editing. Anette Siedler: Formal Analysis, Writing -Reviewing and Editing

☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work