PONE-D-21-30876Comparative analysis of child immunization rates across 30 European countries and identification of underlying positive influencesPLOS ONE

Dear Dr. Pecoraro,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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The study has merits but, in its current version, the manuscript has some major issues that have to be solved regardless of any review. Thus, before sending the manuscript out for the peer review process, I suggest the authors to address these issues. This will substantially fasten the review process.1.Details should be provided on when data on each country characteristics (such as policies) have been extracted. They may vary and we need to know when the assessment was made.2.The description of the Tables is poor overall. There are many crucial details that have not been explained and must be explained. E.g. in Table 1, what is CoV? "Antigen" should be replace by "Vaccine", in Table 2 what 368 observations stands for? No units of measures are given, 3 decimals are not needed, min./max. can be cut, in Table 3, there is no explanation of what is the dependent variable, the title average coverage is wrongly placed, in place of "covariates" or "variables", six decimals are surreal (change the unit of the variable in thoushands), there is no indication that the numbers are referred to beta coefficients, the building of the final model creates confusion (are we searching the best model to evaluated an association, or are we making a statistical exercise?). Why non significant variables have been retained in the final model has to be explained, and once the final, most complete model has been fit, there is no need at all to leave the results of the intermediate models, unless there are very major reasons. As it currently stands, although the aim is straightforward, it is confusing and very difficult to understand. Again, in the results there is a long description of the three models, which is most likely trivial. Please discuss the results of the best model.3.Overall, the writing is fair, but can be improved. The topic is complex, and the authors should try to make the sentences as short as possible. As it currently stands, it is sometimes too complex for the reader to understand the concepts. Some sentences are simply impossible to understand and must be rewritten. E.g. "The inter-country analysis showed that, besides a small set of high-performing countries, the level of variability can be differently associated with countries showing vaccination coverage rates that meet the target of 95% only with some vaccines, or with countries showing low uptake rates related to almost all vaccines".Other sentences are written in Italian and then translated, but must be improved. E.g. "gives much

greater richness of analysis and creates some stable and important findings" or "Though perforce based on snapshot national data". Overall, the writing of manuscript should be revised in depth, keeping in mind that the discussion is very long and only truly essential concepts should be maintained.4.Please address errors such as "Error! Reference source not found" 5.All the figures do not have clear explanations and, as they currently stand, they are impossible to understand.After these issues are addressed, the manuscrpt will proceed to the review process. The study is valid.

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Please submit your revised manuscript by Mar 21 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Lamberto Manzoli, M.D., M.P.H.

Academic Editor

PLOS ONE

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PONE-D-21-30876R1Comparative analysis of pre-Covid19 child immunization rates across 30 European countries and identification of underlying positive societal and system influencesPLOS ONE

Dear Dr. Pecoraro,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

 Please acknowledge that I entirely disagree with the reviewer statements on the lack of time for obligation to show some effects on uptake. Three years are absolutely sufficient to see an effect, and they are indeed the amount of time that Governments typically set to perform an evaluation. Given this, please address the minor issues raised by the reviewer and reduce the emphasis on the conclusions, acknowledging that we cannot have individual data and any conclusion can only be preliminary.

Please submit your revised manuscript by Jun 10 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Lamberto Manzoli, M.D., M.P.H.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

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Reviewer #1: Yes

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: It is well established that vaccine uptake is context and vaccine specific and high uptake depends on numerous inter related complex factors. Using available data the authors set out to explore which factors influence vaccine uptake across 30 European countries.

The findings of this analysis at three levels showed the positive impact of high GDP and tertiary education and young population along with a cohesive management structure, high doctor/nurse ratio, e-health strategies and home based records but the negative impact of mandatory vaccination.

I found this paper somewhat perplexing as there seems to be a number of leaps to conclusions that are not always borne out by the evidence.

For example, the authors found that a high nurse/doctor ratio had a positive effect and argue that this may result in healthcare being more holistic, reflecting person centred values and focussed away from purely biomedical interventions. They acknowledge that the data on nurse/doctor ratio does not allow the extent to which nurses are employed in preventive care or vaccination activities and recommend better information is needed in this respect. This is a fundamental question - could this conclusion lead to countries deciding to employ fewer doctors?!. However, an important issues is that in many countries, vaccination is doctor led rather than nurse led - this information should be easily available.

However, the issue over which I have most comment is the conclusion that mandatory vaccination has a negative relationship with vaccination coverage. Key to this finding is how long the mandatory vaccination policy has been in place. In some of the countries included in this analysis, mandatory vaccination was only introduced or requirements expanded in 2017/2018, the year taken in this project as the ‘anchor year’, in response to wide spread measles outbreaks, giving no time for the effects of mandation. The lower vaccine uptake in these countries may thus have resulted in the introduction of mandation and is not the cause of the low uptake.

Overall, I am not clear about the take home message from this paper other than richer countries, with cohesive management structures have higher vaccination rates. How would a country wishing to improve its vaccination uptake act on these findings? The study is an impressive use of data, but I do not feel takes us much further in understanding the determinants of vaccine uptake.

There are a number of minor details which require explanation for an international readership or correction:

Child e-health strategy, home based records – are both defined, but would benefits from further explanation. For example, in UK, home based records are known as Personal Child Health Records.

Page 16, line 331 – presume this should be ‘immunisation’ data not ‘immunological’

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Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Comparative analysis of pre-Covid19 child immunization rates across 30 European countries and identification of underlying positive societal and system influences

PONE-D-21-30876R2

Dear Dr. Pecoraro,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Lamberto Manzoli, M.D., M.P.H.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

All issues have been addressed.

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