Managing research evidence to inform action: Influencing HIV policy to protect marginalised populations in Pakistan

Abstract

Our aim was to demonstrate that an understanding of the process of how research may (or may not) influence policy and practice is crucial to leverage research findings and bring about evidence-informed policy and its implementation. We describe a process of research design and execution, based on theories of the relationship between evidence and public policy-making, which sought to improve the uptake of evidence into the HIV policy-making process in Pakistan. We designed and implemented specific strategies in research methods, management and dissemination to increase the policy influence by recommendations from a multi-disciplinary research project. Research to policy is complex, rarely linear and causal attribution is problematic. Nonetheless, we believe that, in part, some of the current changes in HIV policy and practice in Pakistan may be due to the managed process of research influence. We offer four key recommendations for those concerned with improving the chances of seeing their research incorporated into policy and practice – these are (1) involve stakeholders in research management; (2) set realistic expectations of research impact; (3) invest in long-term research–policy-maker relationships; and (4) build capacity of end users to use research to demand policy change.     

Compliance to timely vaccination in an Expanded Program on Immunization center of Pakistan

The importance of childhood immunization in prevention of highly fatal diseases and disability cannot be overemphasized. Pakistan has a national Expanded Program on Immunization but the compliance is far below the international benchmark for achieving a herd immunity. Monitoring the compliance to timely receipt of vaccinations is crucial to establishing and preventing disease and disability associated risk in children. There is little or no evidence that reports the timeliness of the vaccinations according to the EPI schedule in Peshawar. The primary objective of the study was to evaluate rate of Fully Immunized Children and to report compliance to the timeliness of vaccine specific schedule during the study period in the EPI center in the capital city of Peshawar, Khyber Pakhtunkhwa province of Pakistan. We collected consecutive retrospective data of the infants enrolled from June 2014 to December 2015 in one EPI center for our study. Out of the total 157 (n) children, fully immunized children (FIC) were 62 (39.5%) and only 19 (12.1%) were FIC with timely visits. Dropouts increased with successive vaccinations with highest for Measles 1 (42%). On-time vaccinations decreased over time, while the proportion of children receiving vaccination outside the ideal window period reaches as high as 46%. The study reports a low compliance to EPI schedule, and also highlights that immunization coverage is not a good indicator of age appropriate vaccinations.     

流感疫苗在高危人群中应用安全性、有效性及接种现状研究新进展

对2020年国内外不同高危人群流感疫苗应用情况发表的相关研究进展进行综述。流感疫苗在高危人群中接种的重要性得到了更多大样本、多中心、高质量循证证据的支持。接种流感疫苗是预防流感最经济有效的措施,目前我国流感疫苗接种率很低,需进一步加大对各类人群流感疫苗接种的科普宣传与教育。建议流感季来临前对研究证据明确的疫苗接种安全有...     

Accessibility and utilization patterns of a mobile medical clinic among vulnerable populations

We mapped mobile medical clinic (MMC) clients for spatial distribution of their self-reported locations and travel behaviors to better understand health-seeking and utilization patterns of medically vulnerable populations in Connecticut. Contrary to distance decay literature, we found that a small but significant proportion of clients was traveling substantial distances to receive repeat care at the MMC. Of 8404 total clients, 90.2% lived within 5 miles of a MMC site, yet mean utilization was highest (5.3 visits per client) among those living 11–20 miles of MMCs, primarily for those with substance use disorders. Of clients making >20 visits, 15.0% traveled >10 miles, suggesting that a significant minority of clients traveled to MMC sites because of their need-specific healthcare services, which are not only free but available at an acceptable and accommodating environment. The findings of this study contribute to the important research on healthcare utilization among vulnerable population by focusing on broader dimensions of accessibility in a setting where both mobile and fixed healthcare services coexist.     

Effects of geographic and economic heterogeneity on the burden of rotavirus diarrhea and the impact and cost-effectiveness of vaccination in Pakistan

Globally, rotavirus is a leading cause of childhood diarrhea and related mortality. Although rotavirus vaccination has been introduced in many countries worldwide, there are numerous low- to middle-income countries that have not yet introduced. Pakistan is one of the countries with the highest number of rotavirus deaths in children under five years. Although rotavirus infection is almost universal among children, mortality is often a result of poor nutrition and lack of access to health care and other aspects of poverty. We assess the impact and cost-effectiveness of introducing childhood rotavirus vaccination in Pakistan. We use household data from the 2012–2013 Demographic Health survey in Pakistan to estimate heterogeneity in rotavirus mortality risk, vaccination benefits, and cost-effectiveness across geographic and economic groups. We estimate two-dose rotavirus vaccination coverage that would be distributed through a routine vaccination program. In addition, we estimate rotavirus mortality (burden), and other measures of vaccine cost-effectiveness and impact by subpopulations of children aggregated by region and economic status. Results indicate that the highest estimated regional rotavirus burden is in Sindh (3.3 rotavirus deaths/1000 births) and Balochistan (3.1 rotavirus deaths/1000 births), which also have the lowest estimated vaccination coverage, particularly for children living in the poorest households. In Pakistan, introduction could prevent 3061 deaths per year with current routine immunization patterns at an estimated $279/DALY averted. Increases in coverage to match the region with highest coverage (Islamabad) could prevent an additional 1648 deaths per year. Vaccination of children in the highest risk regions could result in a fourfold mortality reduction as compared to low risk children, and children in the poorest households have a three to four times greater mortality reduction benefit than the richest. Based on the analysis presented here, the benefits and cost-effectiveness of rotavirus vaccination can be maximized by reaching economically and geographically vulnerable children.     

HIV/AIDS risk behaviors and correlates of injection drug use among drug users in Pakistan

We studied prevalence and correlates of injection drug use, awareness of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and risky behaviors among drug users serviced by a nongovernmental organization catering to drug users in three Pakistani cities (Quetta, Peshawar, and Rawalpindi). Logistic regression analysis was used to identify correlates of injection drug use. Of 608 drug users, 99.8% were male; median age was 32 years, and 44% were married. Most (79.8%) were Pakistani; 15.3% were Afghani. The majority used heroin (98.7%), mostly by inhalation; 15.2% injected drugs. Only 41% had heard of HIV/AIDS, and 30% had been paid for donating blood. Injection drug use and needle sharing were highest in Quetta. Injecting drug users (IDUs) were nearly twice as likely to have donated blood and to have heard about HIV/AIDS compared to other drug users. Interventions to discourage transitions to injection, increase HIV testing, and safeguard the blood supply in Pakistan are urgently needed.     

高风险人群流感疫苗接种现况和免疫策略分析

流感是由流感病毒引起的一种呼吸道传染性疾病,严重疾病负担常见于高风险人群。接种流感疫苗是预防流感及其并发症的有效方法,尤其是对高风险人群。虽然已有部分国家将流感疫苗纳入国家免疫规划,但全球范围内高风险人群流感疫苗接种率仍然较低。目前,流感疫苗在我国仍属于自愿自费接种的非免疫规划疫苗,且全国各地流感疫苗免疫策略差异化明显,接种率与发达国家仍有差距。进一步优化我国流感疫苗全人群免疫策略,加强流感疫苗全人群免疫策略的宣传,降低我国流感的疾病负担,是目前迫切需要解决的问题。     

Poliomyelitis outbreaks in Angola genetically linked to India: risk factors and implications for prevention of outbreaks due to wild poliovirus importations

We conducted an investigation of two outbreaks of poliomyelitis in Angola during 2007-2008 due to wild poliovirus (WPV) genetically linked to India. A case-control study including 27 case-patients and 76 age- and neighborhood-matched control-subjects was conducted to assess risk factors associated with paralytic poliomyelitis, and epidemiologic links to India were explored through in-depth case-patient interviews. In multivariable analysis, case-patients were more likely than control-subjects to be undervaccinated with fewer than four routine doses of oral poliovirus vaccine (adjusted matched odds ratio [aMOR], 4.1; 95% confidence interval [CI], 1.2-13.6) and have an adult household member who traveled outside the province of residence in the 2 months preceding onset of paralysis (aMOR, 3.2; 95% CI, 1.2-8.6). No epidemiologic link with India was identified. These findings underscore the importance of routine immunization to prevent outbreaks following WPV importations and suggest a possible role of adults in sustaining WPV transmission.     

移动医疗APP在重庆某地慢病高危人群慢病管理中的应用效果分析

目的 分析移动医疗APP在基层慢病高危人群慢病管理中的应用效果,研究移动医疗 APP模式应用于慢病管理中的意义。方法 选取2020年1— 12月在重庆某社区卫生服务中心进行体检以及就诊的慢病高危人群。本研究总计纳入慢病高危人群120名。随机分为干预组和对照组,每组各60人。干预组采取移动医疗APP慢病管理模式,对照组采取传统慢病管理模式。比较两组慢病高危人群在干预前和干预12个月后的生理指标控制、自我效能得分及自我管理等情况。结果 生理指标控制上,干预组与对照组末期数据比较,各项指标均低于对照组水平,收缩压（t = 2.045,P = 0.043）、舒张压（t = 2.127,P = 0.036）、血清总胆固醇（t = 2.082,P = 0.04）、空腹血糖（t = 3.720,P＜0.001）差异有统计学意义。自我效能上,干预组末期自我效能总分高于对照组水平（t = -2.923,P = 0.004）,差异有统计学意义（P＜0.05）;自我管理行为上,干预组前后比较吸烟情况（χ2 = 6.911,P = 0.032）、饮酒情况（χ2 = 6.112,P = 0.047）、明显超重或肥胖情况（χ2 = 0.697,P = 0.404）、体力活动情况（χ2 = 4.053,P = 0.044）,干预组慢病高危人群干预末期吸烟、饮酒及缺乏运动或轻体力劳动情况均有所改善,差异有统计学意义（P＜0.05）。肥胖情况前后差异无统计学意义（P＞0.05）。结论 移动医疗APP管理慢病模式有效改善慢病高危人群生理指标水平,提高慢病高危人群自我效能,修正慢病高危人群不良自我管理行为, 填补了传统管理模式的不足,是未来健康行业发展的必然趋势。     

2017-2021年中国肠道病毒71型灭活疫苗接种现状分析

目的了解2017-2021年中国肠道病毒71型(EV71)灭活疫苗接种现状, 为制定手足口病防控和免疫策略提供参考。方法利用中国免疫规划信息管理系统收集的EV71灭活疫苗报告接种剂次数和出生人口数据估算2012年以来各出生队列截至2021年底的全国、分省和分地市EV71灭活疫苗累计接种率, 并分析与接种率水平相关的潜在影响因素。结果截至2021年, 全国2012年以来出生队列EV71灭活疫苗估算累计接种率为24.96%, 各省份估算接种率为3.09%～56.59%, 各地市估算接种率为0～88.17%。不同地区疫苗接种率与该地区既往手足口病报告发病水平和人均可支配收入的相关性均有统计学意义。结论 2017年以来EV71灭活疫苗在全国范围内应用广泛, 但地区间疫苗接种覆盖情况差异较大, 经济相对发达地区接种率较高, 既往疾病流行强度可能对疫苗的接受度和接种服务模式产生一定影响。EV71灭活疫苗接种对手足口病流行的影响还需进一步研究。     

Parental acceptance of and preferences for administration of routine varicella vaccination in the UK: A study to inform policy

ObjectivesTo explore acceptability of and preferences for the introduction of varicella vaccination to the UK childhood immunisation schedule.DesignWe conducted an online cross-sectional survey exploring parental attitudes towards vaccines in general, and varicella vaccine specifically, and their preferences for how the vaccine should be administered.Participants596 parents (76.3% female, 23.3% male, 0.4% other; mean age 33.4 years) whose youngest child was aged 0–5 years.Main outcome measuresWillingness to accept the vaccine for their child and preferences for how the vaccine should be administered (in combination with the MMR vaccine [MMRV], on the same day as the MMR vaccine but as a separate injection [MMR + V], on a separate additional visit).Results74.0% of parents (95% CI 70.2% to 77.5%) were extremely/somewhat likely to accept a varicella vaccine for their child if one became available, 18.3% (95% CI 15.3% to 21.8%) were extremely/somewhat unlikely to accept it and 7.7% (95% CI 5.7% to 10.2%) were neither likely nor unlikely. Reasons provided by parents likely to accept the vaccine included protection from complications of chickenpox, trust in the vaccine/healthcare professionals, and wanting their child to avoid their personal experience of chickenpox. Reasons provided by parents who were unlikely included chickenpox not being a serious illness, concern about side effects, and believing it is preferable to catch chickenpox as a child rather than as an adult. A combined MMRV vaccination or additional visit to the surgery were preferred over an additional injection at the same visit.ConclusionsMost parents would accept a varicella vaccination. These findings highlight parents’ preferences for varicella vaccine administration, information needed to inform vaccine policy and practice and development of a communication strategy.     

Vaccination status and sequence of vaccinations as risk factors for hospitalisation among outpatients in a high mortality country

Background

Most developing countries are implementing the WHO immunisation programme. Although vaccines reach most children, many modifications of the recommended schedule are observed in practice. We investigated the association between vaccination status and risk of hospitalisation in Guinea-Bissau.

Methods

From May 2003 to May 2004, all consultations of children less than five years of age at the outpatient clinic of the paediatric ward at the national hospital in Bissau were registered. For each consultation, information was collected about the child's name, sex, age and socio-cultural conditions, as well as diagnosis and whether the child was hospitalised. Information about vaccinations was also registered from the child's vaccination card. We analysed the association between vaccination status and risk of hospitalisation in age intervals according to the pre-dominant vaccines. We particularly emphasised the comparison of those who had received the recommended vaccination for the age groups and those who were delayed and only had the previous vaccinations. We also examined those who had received the vaccines out of sequence.

Results

Information about vaccinations was available for 11,949 outpatient children of whom 2219 (19%) were hospitalised. Among children less than 3 months of age, unvaccinated children compared to BCG children had as expected a higher risk of hospitalisation; controlled for important determinants of hospitalisation, the hospitalisation risk ratio (HRR) was 1.99 (95% CI 1.37-2.89). In contrast, there was no difference in the HRR for children aged 1 ½ -8 months who were delayed and had only received BCG compared to those who as recommended had received diphtheria-tetanus-pertussis (DTP) vaccine after BCG (HRR = 1.10 (0.77-1.59)). In the age interval 9-17 months of age, children who were delayed and had only received DTP had significantly higher risk of hospitalisation compared with children who as recommended had measles vaccine (MV) as the most recent vaccination (HRR = 1.39 (1.16-1.66)). Having received DTP after MV (HRR = 1.60 (1.15-2.24)) or MV and DTP simultaneously (HRR = 1.51 (1.16-1.97)) was also associated with higher risk than MV only as most recent vaccination. In contrast, the children aged 18-59 months who as recommended had received a DTP booster after MV did not have lower risk of hospitalisations compared with children who were delayed and had received only MV (RR = 0.90 (0.75-1.07)). After 9 months of age, there was a significant difference in the female-male HRR for children who had MV (HRR = 0.85 (0.72-1.00)) or DTP (HRR = 1.08 (0.96-1.22)) as most recent vaccination (p = 0.02, test of interaction).

Conclusion

Following the recommended vaccination schedule for BCG and MV is associated with a reduced risk of hospitalisation but this is not the case for DTP and booster DTP. Receiving DTP simultaneously with MV or after MV is associated with increased risk of hospitalisation. Vaccines have sex-differential effects on the risk of hospitalisation.     

Bias in a binary risk behaviour model subject to inconsistent reports and dropout in a South African high school cohort study

We describe a methodology for analysing self‐reported risk behaviour transitional patterns in a binary outcome variable, subject to misclassification and a large loss to follow‐up. The motivation stems from the analysis of self‐reported transitional patterns in responses to the question ‘have you ever smoked a whole cigarette?’ in a cohort of South African school children. The partially complete records analysis (PCRA) introduced, estimates the transitional probability as: the ratio of the joint probability of the response at two time points based on the complete records for this time sequence over the marginal probabilities of the response based on the complete records at the first time point, and assumes a non‐informative missing pattern. A comparison was made using un‐weighted complete records and inverse probability weighted logistic regression. The estimates of the probabilities of reporting ever having smoked a cigarette obtained from the three methods were similar for a particular transition. The PCRA method lacked precision compared with the inverse probability weighted logistic regression. A simulation study indicated an association between bias and reporting error in all three methods. The PCRA method can be considered as a method for the estimation of transition probabilities in a cohort study where there is consistency in the self‐reported risk behaviour pattern and the sample size is large at baseline. The inverse probability weighting approach is more precise and is suitable for this setting in order to determine risk factors for the incidence of self‐reported substance used in a cohort with a high dropout rate. Copyright © 2008 John Wiley & Sons, Ltd.     

基于移动医疗APP营养管理干预策略对早产儿出院后营养状况及体格发育的作用

目的探讨基于移动医疗APP营养管理干预策略对早产儿出院后营养状况及体格发育的作用。 方法选取2018年1月至2020年12月,南宁市第二人民医院与广州医科大学附属深圳沙井医院新生儿病房收治的60例早产儿为研究对象。采用随机数字表法,将其分为研究组(n＝30)与对照组(n＝30)。对2组早产儿,分别采用基于移动医疗APP、常规电话随访策略进行出院后营养管理干预,并随访6个月。采用成组t检验、χ²检验,对2组早产儿生长发育指标、《小儿智能发育检查表》评分、生化指标、疾病发生率进行统计学比较。2组早产儿性别构成比、出生胎龄、出生体重等一般临床资料比较,差异均无统计学意义(P>0.05)。本研究遵循的程序经过南宁市第二人民医院医学伦理委员会批准(审批文号：20180108),与纳入研究早产儿监护人均签署临床研究知情同意书。 结果①干预后研究组早产儿身高、头围、体重分别为(66.7±6.4) cm、(7.7±2.2) kg、(42.0±3.4) cm,均显著优于对照组的(60.3±5.3) cm、(7.0±1.5) kg、(39.2±2.5) cm,并且差异均有统计学意义(t＝4.187、P<0.001,t＝2.291、P＝0.029,t＝3.575、P<0.001)。②干预后,研究组早产儿《智能量表》与《运动量表》评分分别为(91.1±10.4)分、(48.6±5.2)分,均显著高于对照组的(78.2±8.2)分、(42.3±4.1)分,并且差异均有统计学意义(t＝5.287、5.235,P<0.001)。③干预后,研究组早产儿血清前白蛋白(PA)、视黄醇结合蛋白(RBP)水平分别为(136.1±8.5) mg/L、(140.7±16.9) mg/L,均显著高于对照组的(120.3±7.0) mg/L、(126.6±14.3) mg/L,并且差异均有统计学意义(t＝7.808、3.498,P<0.001)。④研究组早产儿疾病发生率为10.0%(3/30),显著低于对照组的36.7%(11/30),并且差异有统计学意义(χ²＝5.583、P＝0.016)。 结论对早产儿采取基于移动医疗APP营养管理干预策略,可显著提高早产儿出院后营养状况,促进其生长发育,减少早产儿疾病发生,进而提高其生存质量。     

长春市妇女宫颈疾病流行现状及高危因素分析

目的:探讨引起长春市妇女宫颈疾病的危险因素,为制定预防措施提供依据。方法:采用分层随机抽样方法抽取长春市2 426名25~65岁的已婚女性作为调查对象,通过统一的问卷调查、专职医生做妇科内诊检查及宫颈液基细胞(TCT)检测,诊断不明者行HPV、阴道镜、宫颈组织病理等诊断方法进一步检查确诊。结果:被检查的2 426名女性中,宫颈疾病患病率为21.15%,其中宫颈柱状外翻发病率占第1位。宫颈病变与性行为、人乳头瘤病毒感染、分娩因素、吸烟、避孕方法等有关。结论:应加大宫颈保健知识的宣传力度和普查范围,降低其患病率。     

合肥市2010年入托入学儿童预防接种证查验情况分析

目的了解合肥市入托、入学儿童查验接种证工作开展现况及影响因素,为提高规划疫苗接种率和加强学校传染病预防控制提供科学依据。方法按照统一方案,对合肥市2010年入托、入学儿童预防接种证进行查验。结果托幼机构及小学查验率为100%,持证率为97.7%。除6岁A+C流脑苗、百破二联(百白破)疫苗、甲肝苗接种率低于90%外,其他疫苗接种率均超过90%。结论应采取多种措施,促进入托入学接种证查验和计划免疫工作。     

顺义区禽流感高危险职业机构职业防护现况调查

目的了解顺义区禽流感高危险职业机构职业防护现状,为政府进一步开展此类机构人禽流感防控工作提供数据支持。方法2006年4~5月,采用分层整群随机抽样的方法抽取顺义区禽流感高危险职业机构36家,从业人员191名,分别进行机构职业防护管理情况和从业人员防护行为的问卷调查。结果调查机构设有各项禽流感职业防护管理项目的比率均低于40.0%,国有集体、合资机构设有各种管理项目的比率显著高于个体机构(P<0.05);大型机构设有各种管理项目的比率显著高于小型机构(P<0.05)。从业人员穿戴各种防护用具的比率在85.3%~16.8%之间,合资企业显著高于个体企业(P<0.05),大型企业显著高于小型企业(P<0.05)。结论顺义区禽流感高危险机构职业防护现状呈两极分化趋势,大型机构、合资机构职业防护情况好于小型机构、个体机构,建议有关部门应采取有效措施,加强职业防护措施的落实。     

Social and demographic patterns of influenza vaccination coverage in Norway,influenza seasons 2014/15 to 2020/21

AimsTo examine influenza vaccination coverage among risk groups (RG) and health care workers (HCW), and study social and demographic patterns of vaccination coverage over time.MethodsVaccination coverage was estimated by self-report in a nationally representative telephone survey among 14 919 individuals aged 18–79 years over seven influenza seasons from 2014/15 to 2020/21. We explored whether belonging to an influenza RG (being >=65 years of age and/or having >=1 medical risk factor), being a HCW or educational attainment was associated with vaccination status using logistic regression.ResultsVaccination coverage increased from 27 % to 66 % among individuals 65–79 years, from 13 % to 33 % among individuals 18–64 years with >=1 risk factor, and from 9 % to 51 % among HCWs during the study period. Being older, having a risk factor or being a HCW were significantly associated with higher coverage in all multivariable logistic regression analyses. Higher education was also consistently associated with higher coverage, but the difference did not reach significance in all influenza seasons. Educational attainment was not significantly associated with coverage while coverage was at its lowest (2014/15–2017/18), but as coverage increased, so did the differences. Individuals with intermediate or lower education were less likely to report vaccination than those with higher education in season 2018/19, OR = 0.61 (95 % CI 0.46–0.80) and OR = 0.58 (95 % CI 0.41–0.83), respectively, and in season 2019/20, OR = 0.69 (95 % CI 0.55–0.88) and OR = 0.71 (95 % CI 0.53–0.95), respectively. When the vaccine was funded in the COVID-19 pandemic winter of 2020/21, educational differences diminished again and were no longer significant.ConclusionsWe observed widening educational differences in influenza vaccination coverage as coverage increased from 2014/15 to 2019/20. When influenza vaccination was funded in 2020/21, differences in coverage by educational attainment diminished. These findings indicate that economic barriers influence influenza vaccination decisions among risk groups in Norway.