Knowledge of Norovirus and Attitudes toward a Potential Norovirus Vaccine in Rural Guatemala: A Cross-Sectional Exploratory Survey

Vaccine hesitancy appears to be an increasing problem in low- and middle-income countries (LMICs) and can be categorised into contextual (i.e., political and cultural barriers) individual/group (i.e., risk/benefit and knowledge), and vaccine-specific (i.e., schedule and cost) influences. Like many LMICs, Guatemala has a high burden of enteric diseases, including norovirus. In anticipation of forthcoming vaccines, the researchers characterised norovirus vaccine attitudes in a rural Guatemalan community and explored associations between sociodemographic factors, vaccine hesitancy, and willingness to pay (WTP).

Cluster-randomised households with children aged 6 weeks to 17 years were enrolled into one of 2 norovirus surveillance studies: (i) a prospective cohort (N = 207 households) and (ii) 2 separate, community-based, cross-sectional surveys (N = 420 households). A 66-question vaccine knowledge and attitude survey was administered to the heads of households via in-person interview by local study nurses. The survey was adapted, in part, from a previously validated World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) on Vaccine Hesitancy report and a survey assessing knowledge and attitudes about dengue virus and vaccine hesitancy.

Most households demonstrated an appropriate understanding of norovirus transmission and symptoms. Most respondents (84%) reported receiving health information from the Ministry of Health (MOH), and 544 (97%) indicated interest in a norovirus vaccine. Households with higher education had greater WTP for a vaccine (prevalence ratios = 2.2, 95% confidence interval (CI): 1.2-3.1).

The 4% (N = 20) of respondents who were uninterested in a norovirus vaccine were 9.8 (95% CI 1.9-51.6) times as likely to believe that vaccines in general do not prevent serious disease and 4.3 (95% CI 1.4-13.7) times as likely to have refused a vaccine in the past. These households receive their information about diarrhoea primarily from the MOH (80%), neighbours (40%), and television (25%). The MOH was also the most trusted source for information about diarrhoea in this group (85%). Households with low WTP were more likely to be crowded, receive their medical care from a pharmacy, and obtain their health information from the radio and MOH.

In other studies cited here, fear of adverse effects, exposure to rumours regarding a vaccine, and lack of awareness are among the factors associated with decreased vaccine acceptance. On the other hand, a physician's recommendation for a vaccine and known protection against severe diseases have previously been shown to improve vaccine acceptability. "Although more data are needed, MOH and community-level education may offer an approach to overcome hesitancy in this community...."

"These results suggest that a future norovirus vaccination program could be acceptable and feasible even in rural areas." However, "[a]s norovirus and other enteric vaccines advance in their preclinical development, future studies should explore vaccine acceptability in relation to the estimated efficacy, the number of doses, additional variables (household income and ethnicity), and the behaviors and determinants of the small group expressing some vaccine hesitancy."