Intention to accept pertussis vaccine among pregnant women in Karachi, Pakistan Mariam Siddiqui a , Afshin Alaf Khan a , Aiden Kennedy Varan a , Alejandra Esteves-Jaramillo b , Shazia Sultana c , Asad S. Ali c , Anita K.M. Zaidi c , Saad B. Omer a,d,e,⇑ a Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, USA b National Center for Child and Adolescent Health, Ministry of Health, Francisco de P. Miranda 177, Lomas de Plateros, Álvaro Obregón, 01600 Mexico City, Mexico c Department of Pediatrics and Child Health, The Aga Khan University, Karachi 74800, Pakistan d Emory Vaccine Center, 201 Dowman Drive, Atlanta, GA 30322, USA e Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA 30322, USA article info Article history: Received 30 January 2017 Received in revised form 13 August 2017 Accepted 15 August 2017 Available online xxxx Keywords: Pertussis Tdap Maternal immunization Antenatal vaccination Pregnant women Vaccine acceptance Pakistan abstract Background: Maternal immunization against pertussis is a potential strategy to protect young infants from severe disease. We assessed factors associated with intention to accept pertussis vaccination among pregnant women in Karachi, Pakistan. Methods: We conducted a cross-sectional survey between May and August 2013 in pregnant women who visited healthcare centers in urban slums of Karachi city. Women completed a survey examining socio- demographic factors, vaccination history, knowledge on pertussis disease, perception of vaccine recom- mendation sources, and potential influences on vaccine decision-making. Results: Of the 283 participants, 259 (92%) provided their intention to either accept or decline pertussis vaccination. Eighty-three percent women were willing to accept the pertussis vaccine if offered during pregnancy. About half (53%) of the participants had ever heard of pertussis disease. Perceptions of pertus- sis vaccine efficacy, safety, and disease susceptibility were strongly associated with intention to accept pertussis vaccine (p < 0.01). Healthcare providers, Ministry of Health, and mass media were considered as highly reliable sources of vaccine recommendation and associated with intention to accept antenatal pertussis vaccination (p < 0.001). Healthcare provider recommendation was a common reason cited by respondents for pregnant women to accept antenatal pertussis vaccination (p = 0.0005). However, opin- ion of primary decision-makers in the family (husbands and in-laws) was a crucial reason cited by respondents for pregnant women to reject pertussis vaccination in pregnancy (p = 0.003). Conclusion: Antenatal pertussis vaccination initiatives in South Asia should strongly consider inclusion of family members, healthcare providers, national health ministries, and mass media to help implement new vaccination programs. Ó 2017 Elsevier Ltd. All rights reserved. 1. Introduction Pertussis, or whooping cough, is a highly contagious acute respiratory infection. Infants too young to be completely vacci- nated against pertussis are at the highest risk of experiencing sev- ere complications and hospitalizations [1]. Family members and caregivers are often recognized as sources of pertussis transmis- sion in infants [2–5]. Antenatal vaccination with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) is a potential strategy to prevent pertussis in mothers and their infants by passive transfer of maternal anti-pertussis antibodies and decreasing exposure through cocooning [3]. Since 2012, four coun- tries – US, UK, Australia, and New Zealand – now recommend that all pregnant women receive a single dose of pertussis vaccination in late second or third trimester with every pregnancy irrespective of previous Tdap vaccination history [2,6–8]. Pakistan has one of the highest burden of childhood mortality attributable to vaccine-preventable diseases. Acute respiratory infections in Pakistan are the third leading cause of death in chil- dren aged under five years [9]. Moreover, in 2010 the annual inci- dence of acute lower respiratory infections in Pakistan ranked highest (6.7 million) among countries in the WHO Eastern http://dx.doi.org/10.1016/j.vaccine.2017.08.033 0264-410X/Ó 2017 Elsevier Ltd. All rights reserved. ⇑ Corresponding author at: Emory University, Rollins School of Public Health and School of Medicine, 1518 Clifton Rd, Rm 7017, Atlanta, GA 30322, USA. E-mail address: somer@emory.edu (S.B. Omer). Vaccine xxx (2017) xxx–xxx Contents lists available at ScienceDirect Vaccine journal homepage: www.elsevier.com/locate/vaccine Please cite this article in press as: Siddiqui M et al. Intention to accept pertussis vaccine among pregnant women in Karachi, Pakistan. Vaccine (2017), http://dx.doi.org/10.1016/j.vaccine.2017.08.033