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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Julie Liao, Charles Minicucci, and Anna Nicholson, Rapporteurs Forum on Microbial Threats Board on Global Health Health and Medicine Division PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS   500 Fifth Street, NW   Washington, DC 20001 This activity was supported by contracts between the National Academy of Sciences and the Burroughs Wellcome Fund (10005347), Johnson & Johnson (10004834), National Institutes of Health (10004179), New Venture Fund (10005366), Uni- formed Services University of the Health Sciences (10003626, 10004736, 10005329), U.S. Agency for International Development (10004113), U.S. Department of Health and Human Services (10004491, 10004738, 10005070), U.S. Department of Home- land Security (10004697), and U.S. Department of Veterans Affairs (10004767, 10005209). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/26134 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2021 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medi- cine. 2021. The critical public health value of vaccines: Tackling issues of access and hesitancy. Washington, DC: The National Academies Press. https://doi.org/ 10.17226/26134. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Con- gress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the char- ter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typi- cally include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

PLANNING COMMITTEE ON THE CRITICAL PUBLIC HEALTH VALUE OF VACCINES: TACKLING ISSUES OF ACCESS AND HESITANCY1 HEIDI LARSON (Co-Chair), Professor of Anthropology, Risk and Decision Science, London School of Tropical Hygiene & Medicine; Director, Vaccine Confidence Project MATTHEW ZAHN (Co-Chair), Medical Director, Division of Epidemiology and Assessment, Orange County Public Health Care Agency KEVIN ANDERSON, Senior Program Manager, Science and Technology Directorate, U.S. Department of Homeland Security ALISON BUTTENHEIM, Associate Professor of Family and Community Health and Associate Professor of Health Policy, University of Pennsylvania School of Nursing and Perelman School of Medicine ANDREW CLEMENTS, Deputy Director, Pandemic Influenza and Other Emerging Threats Unit, U.S. Agency for International Development AMANDA COHN, Executive Secretariat, Advisory Committee on Immunization Practices and Acting Chief Medical Officer, National Center for Immunization and Respiratory Diseases, U.S. Centers for Disease Control and Prevention PETER DASZAK, President, EcoHealth Alliance EVA HARRIS, Professor, Division of Infectious Diseases and Vaccinology; Director, Center for Global Public Health, University of California, Berkeley ELIZABETH D. HERMSEN, Head, Global Antimicrobial Stewardship and Health Equity in Infectious Disease, Merck & Co., Inc. NONI MacDONALD, Professor, Department of Pediatrics, Dalhousie University WALTER ORENSTEIN, Professor, Emory University; Associate Director, Emory Vaccine Center; Director, Emory Vaccine Policy and Development 1  The planning committee’s role was limited to planning the workshop, and the Proceed- ings of a Workshop was prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus. v PREPUBLICATION COPY—Uncorrected Proofs

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FORUM ON MICROBIAL THREATS1 PETER DASZAK (Chair), President, EcoHealth Alliance KENT E. KESTER (Vice Chair), Vice President and Head, Translational Science and Biomarkers, Sanofi Pasteur RIMA F. KHABBAZ (Vice Chair), Director, National Center for Emerging Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention EMILY ABRAHAM, Director, External Affairs and Policy, Johnson & Johnson Global Public Health KEVIN ANDERSON, Senior Program Manager, Science and Technology Directorate, U.S. Department of Homeland Security CRISTINA CASSETTI, Deputy Division Director, Division of Microbiology and Infectious Diseases, National Institute of Allergies and Infectious Diseases, National Institutes of Health ANDREW CLEMENTS, Senior Technical Advisor, Emerging Threats Division, U.S. Agency for International Development MARCOS A. ESPINAL, Director, Communicable Diseases and Health Analysis, Pan American Health Organization EVA HARRIS, Professor, Division of Infectious Diseases and Vaccinology; Director, Center for Global Public Health, University of California, Berkeley ELIZABETH D. HERMSEN, Head, Global Antimicrobial Stewardship and Health Equity in Infectious Disease, Merck & Co., Inc. CHRISTOPHER HOUCHENS, Director, Division of Chemical, Biological, Radiological and Nuclear Countermeasures, Biomedical Advanced Research and Development Authority, U.S. Department of Health and Human Services CHANDY C. JOHN, Director, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine MARK G. KORTEPETER, Director, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences JONNA A. K. MAZET, Distinguished Professor of Epidemiology and Disease Ecology; Founding Executive Director, One Health Institute, University of California, Davis VICTORIA McGOVERN, Senior Program Officer, Burroughs Wellcome Fund 1  The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. vii PREPUBLICATION COPY—Uncorrected Proofs

SALLY A. MILLER, Distinguished Professor of Food, Agricultural and Environmental Sciences, The Ohio State University SUERIE MOON, Director of Research, Global Health Centre; Visiting Lecturer, Graduate Institute of International and Development Studies, Geneva; Adjunct Lecturer, Harvard T.H. Chan School of Public Health KUMANAN RASANATHAN, Health Systems Coordinator, Office of the WHO Representative in Cambodia, World Health Organization (WHO) National Academies of Sciences, Engineering, and Medicine Staff GILLIAN BUCKLEY, Senior Program Officer (until June 2020) EDITH AMPONSAH, Associate Program Officer (until July 2020) HANNAH GOODTREE, Senior Program Assistant (until August 2020) JULIE LIAO, Associate Program Officer (from August 2020) CHARLES MINICUCCI, Research Assistant (from July 2020) CLAIRE BIFFL, Senior Program Assistant (from March 2021) JULIE PAVLIN, Director, Forum on Microbial Threats; Senior Director, Board on Global Health viii PREPUBLICATION COPY—Uncorrected Proofs

Reviewers T his Proceedings of a Workshop was reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engi- neering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review com- ments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: JAMES M. HUGHES, Emory University DAVID KIM, U.S. Department of Health and Human Services AARON SCHERER, University of Iowa Carver College of Medicine Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by GERALD T. KEUSCH, Boston University. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies. ix PREPUBLICATION COPY—Uncorrected Proofs

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Acknowledgments T he workshop summarized in this proceedings is the product of many valuable contributions. Special thanks go to the presenters and dis- cussants who gave generously of their time and expertise to make the event possible. A full list of the speakers and moderators and their biographical information may be found in Appendix C. xi PREPUBLICATION COPY—Uncorrected Proofs

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Contents ACRONYMS AND ABBREVIATIONS xix 1 INTRODUCTION 1 Workshop Objectives, 2 Organization of the Proceedings of the Workshop, 3 2  GLOBAL VACCINE UPTAKE DURING THE COVID-19 PANDEMIC AND THE STATE OF VACCINE CONFIDENCE 5 Impact of the COVID-19 Pandemic on Immunization Services and Access, 5 Global Vaccine Confidence and Strategies to Enhance Uptake, 12 Discussion, 18 3 IMPROVING ACCESS AND CLOSING THE GLOBAL IMMUNIZATION GAP 23 Applying an Equity Lens to Immunization to Close the Global Immunization Gap, 24 Reducing Barriers and Increasing Vaccine Uptake Among Adults, 32 Using Mobile Health Interventions to Improve Vaccination Coverage, 39 The Role of Community-Based Pharmacy Interventions in Increasing Vaccine Access, 45 Discussion, 49 xiii PREPUBLICATION COPY—Uncorrected Proofs

xiv CONTENTS 4 ASSESSING GLOBAL AND LOCAL DRIVERS OF VACCINE HESITANCY 57 Vaccine-Attributable Severe Dengue in the Philippines and the Impact on National Immunization Programs, 58 Dengue and Dengvaxia, 58 Measuring Behavioral and Social Drivers of Vaccination, 62 Understanding Drivers of Vaccine Hesitancy, 66 The Increasing Vaccination Model, 70 Discussion, 74 5 A SYSTEMS APPROACH TO INCREASING VACCINE CONFIDENCE AND UPTAKE: OPPORTUNITIES IN RESEARCH, COMMUNICATION, LEGISLATION, AND TECHNOLOGY  85 Legal Approaches to Promote Parental Compliance with Childhood Vaccines in the United States, 86 Impact of Eliminating Nonmedical Exemptions in California, 89 Harnessing Cultural Insights to Increase Vaccination Uptake, 94 The Role of Physicians in Building Vaccine Confidence and Acceptance, 97 Communicating with Vaccine-Hesitant Parents, 101 Discussion, 107 6 A SYSTEMS APPROACH TO INCREASING VACCINE CONFIDENCE AND UPTAKE: OPPORTUNITIES FOR COMMUNITY-BASED STRATEGIES 115 Social Mobilization as a Strategy to Increase Vaccine Acceptance and Uptake, 116 Adapting COM-B for the Tailoring Immunization Programmes Approach to Increase Vaccination Acceptance and Uptake, 121 Engaging with Faith Communities to Increase Vaccine Acceptance and Uptake in a Charedi Orthodox Jewish Community, 130 Engaging with Immigrant Communities to Increase Vaccine Acceptance and Uptake in a Somali American Community, 133 Discussion, 138 7 REFLECTIONS AND WAYS FORWARD 143 New Vaccines in the Midst of an Outbreak, 144 Inoculating Against Misinformation and Rebuilding the Public’s Trust in Science, 154 Visionary Statements on Priorities in Building Vaccine Acceptance and Uptake for the Next Generation, 165 PREPUBLICATION COPY—Uncorrected Proofs

CONTENTS xv Discussion, 172 Closing Remarks, 175 REFERENCES 177 APPENDIXES A Workshop Statement of Task 185 B Workshop Agenda 187 C Speaker and Moderator Biographies 193 PREPUBLICATION COPY—Uncorrected Proofs

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Boxes, Figures, and Tables BOXES 2-1 Immunization Service Interruptions Caused by the COVID-19 Pandemic, 6 2-2 Lessons from Current Evidence on Strategies to Increase Vaccine Acceptance, 18 5-1 Exemption Provisions Under California’s Bill SB276, 91 5-2 Example of Motivational Interviewing for Vaccine Conversations, 106 FIGURES 2-1 Relative differences in diphtheria, tetanus, and pertussis vaccine dose 3 (2019 versus 2020), 11 3-1 Zero-dose, underimmunized, and immunized children in Gavi- supported countries (2000–2019), 26 5-1 Immunity Charm bracelet, 96 5-2 Continuum of vaccine acceptance, 102 xvii PREPUBLICATION COPY—Uncorrected Proofs

xviii BOXES, FIGURES, AND TABLES TABLES 3-1 Vaccine Coverage in Gavi-Supported Countries (2000, 2019), 25 3-2 Cost Burden of Four Adult Vaccine-Preventable Diseases in Persons Older Than 65 (United States, 2013), 33 3-3 Influenza Vaccination Coverage Among Adults (United States, 2015–2019), 34 PREPUBLICATION COPY—Uncorrected Proofs

Acronyms and Abbreviations ACIP Advisory Committee on Immunization Practices AFRO WHO Regional Office for Africa AMRO WHO Regional Office for the Americas APhA American Pharmacists Association BeSD behavioral and social drivers CDC U.S. Centers for Disease Control and Prevention CEPI Coalition for Epidemic Preparedness Innovations COVID-19 coronavirus disease 2019 DTP diphtheria, tetanus, and pertussis vaccine (pediatric) EPI Expanded Programme on Immunization (WHO) FDA U.S. Food and Drug Administration GACVS Global Advisory Committee on Vaccine Safety HPV human papillomavirus IEP individualized education program IFRC International Federation of Red Cross and Red Crescent Societies IPC infection prevention and control xix PREPUBLICATION COPY—Uncorrected Proofs

xx ACRONYMS AND ABBREVIATIONS LMIC low- or middle-income country LSHTM London School of Hygiene & Tropical Medicine MCV measles-containing vaccine MERS Middle East respiratory syndrome MMR measles, mumps, and rubella MOH Ministry of Health NGO nongovernmental organization NIH National Institutes of Health NITAG National Immunization Technical Advisory Group (WHO) OR odds ratio PHE Public Health England PIRI periodic intensification of routine immunization (WHO) PPE personal protective equipment RCT randomized controlled trial SAGE  Strategic Advisory Group of Experts on Immunization (WHO) SARS severe acute respiratory syndrome SARS-CoV-2 severe acute respiratory syndrome coronavirus 2 SMS short message service TIP Tailoring Immunization Programmes UCI universal child immunization UNICEF United Nations Children’s Fund VAERS Vaccine Adverse Event Reporting System VSD Vaccine Safety Datalink WHO World Health Organization PREPUBLICATION COPY—Uncorrected Proofs

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Immunization against disease is among the most successful global health efforts of the modern era, and substantial gains in vaccination coverage rates have been achieved worldwide. However, that progress has stagnated in recent years, leaving an estimated 20 million children worldwide either undervaccinated or completely unvaccinated. The determinants of vaccination uptake are complex, mutable, and context specific. A primary driver is vaccine hesitancy - defined as a "delay in acceptance or refusal of vaccines despite availability of vaccination services". The majority of vaccine-hesitant people fall somewhere on a spectrum from vaccine acceptance to vaccine denial. Vaccine uptake is also hampered by socioeconomic or structural barriers to access.

On August 17-20, 2020, the Forum on Microbial Threats at the National Academies of Sciences, Engineering, and Medicine held a 4-day virtual workshop titled The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy. The workshop focused on two main areas (vaccine access and vaccine confidence) and gave particular consideration to health systems, research opportunities, communication strategies, and policies that could be considered to address access, perception, attitudes, and behaviors toward vaccination. This publication summarizes the presentations and discussion of the workshop.

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