Pakistan's expanded programme on immunization: An overview in the context of polio eradication and strategies for improving coverage

Since its inception in 1978, Pakistan's Expanded Programme on Immunization (EPI) has contributed significantly towards child health and survival in Pakistan. However, the WHO-estimated immunization coverage of 88% for 3 doses of Diptheria-Tetanus-Pertussis vaccine in Pakistan is likely an over-estimate. Many goals, such as polio, measles and neonatal tetanus elimination have not been met. Pakistan reported more cases of poliomyelits in 2011 than any other country globally, threatening the Global Polio Eradication Initiative. Although the number of polio cases decreased to 58 in 2012 through better organized supplementary immunization campaigns, country-wide measles outbreaks with over 15,000 cases and several hundred deaths in 2012–13 underscore sub-optimal EPI performance in delivering routine immunizations. There are striking inequities in immunization coverage between different parts of the country. Barriers to universal immunization coverage include programmatic dysfunction at lower tiers of the program, socioeconomic inequities in access to services, low population demand, poor security, and social resistance to vaccines among population sub-groups. Recent conflicts and large-scale natural disasters have severely stressed the already constrained resources of the national EPI. Immunization programs remain low priority for provincial and many district governments in the country. The recent decision to devolve the national health ministry to the provinces has had immediate adverse consequences. Mitigation strategies aimed at rapidly improving routine immunization coverage should include improving the infrastructure and management capacity for vaccine delivery at district levels and increasing the demand for vaccines at the population level. Accurate vaccine coverage estimates at district/sub-district level and local accountability of district government officials are critical to improving performance and eradicating polio in Pakistan.     

Contribution of polio eradication initiative to strengthening routine immunization: Lessons learnt in the WHO African region

BackgroundImportant investments were made in countries for the polio eradication initiative. On 25 September 2015, a major milestone was achieved when Nigeria was removed from the list of polio-endemic countries. Routine Immunization, being a key pillar of polio eradication initiative needs to be strengthened to sustain the gains made in countries. For this, there is a huge potential on building on the use of polio infrastructure to contribute to RI strengthening.MethodsWe reviewed estimates of immunization coverage as reported by the countries to WHO and UNICEF for three vaccines: BCG, DTP3 (third dose of diphtheria-tetanus toxoid- pertussis), and the first dose of measles-containing vaccine (MCV1).We conducted a systematic review of best practices documents from eight countries which had significant polio eradication activities.ResultsImmunization programmes have improved significantly in the African Region. Regional coverage for DTP3 vaccine increased from 51% in 1996 to 77% in 2014. DTP3 coverage increased >3 folds in DRC (18–80%) and Nigeria from 21% to 66%; and >2 folds in Angola (41–87%), Chad (24–46%), and Togo (42–87%). Coverage for BCG and MCV1 increased in all countries. Of the 47 countries in the region, 18 (38%) achieved a national coverage for DTP3 ⩾90% for 2 years meeting the Global Vaccine Action (GVAP) target. A decrease was noted in the Ebola-affected countries i.e., Guinea, Liberia and Sierra Leone.ConclusionsPEI has been associated with increased spending on immunization and the related improvements, especially in the areas of micro planning, service delivery, program management and capacity building. Continued efforts are needed to mobilize international and domestic support to strengthen and sustain high-quality immunization services in African countries. Strengthening RI will in turn sustain the gains made to eradicate poliovirus in the region.     

Road traffic injuries in urban Africa and Asia: a policy gap in child and adolescent health

OBJECTIVE: This study highlights the burden of urban road traffic injuries (RTIs) in children and young adults in South Asia and Sub-Saharan Africa to heighten awareness of current limitations in child health policies, and to direct future research and intervention development. METHODS: Comparative analysis of recent Sub-Saharan Africa and South Asia reviews of RTIs, World Health Organization (WHO) Global Burden of Disease statistics, and the Bangladesh Health and Injury Survey. PARTICIPANTS: Children aged 0-18 years in South Asia and Sub-Saharan Africa reviews, aged 0-14 years in the WHO data, and aged 1-17 years in the Bangladeshi data. RESULTS: Child pedestrians comprise the largest proportion of urban RTI victims. More healthy life years were lost per 1000 children aged 0-18 years in South Asia than Sub-Saharan Africa. Disability-adjusted life years lost per 1000 children aged 0-14 years was greater in Africa than South-east Asia. South-east Asia has the greatest overall incidence of RTIs; however, Africa has poorer reported outcomes for children aged 0-14 years. CONCLUSION: These data sources point to the salience of intervening in RTIs in children to prevent a predicted boom in the RTI burden in children, particularly in the poorest regions of the world. However, child health policies in these regions have not yet embraced RTI, either in research or programmes.     

某矿区儿童家长计划免疫知识及态度调查

【目的】了解矿区儿童家长对计划免疫知识的掌握程度及态度,为进一步改善免疫接种工作提供科学依据。【方法】自行设计调查表,采取整群抽样的方法,对某矿区667位儿童家长进行问卷调查。【结果】父母文化程度是影响计划免疫知识掌握情况的主要因素(F=9.28,P<0.01);常住人口知识掌握程度高于流动人口(t=2.089,P<0.05);经多因素Logistic分析显示:儿童的性别、家庭的子女数、家长的知识掌握程度是影响儿童家长态度的主要因素。【结论】在今后的预防接种工作中要加强疫苗知识的普及,以改变儿童家长对疫苗接种的认识态度。     

Successful introduction of an underutilized elderly pneumococcal vaccine in a national immunization program by integrating the pre-existing public health infrastructure

BackgroundAlthough pneumococcal vaccines had been recommended for the elderly population in South Korea for a considerable period of time, the coverage has been well below the optimal level. To increase the vaccination rate with integrating the pre-existing public health infrastructure and governmental funding, the Korean government introduced an elderly pneumococcal vaccination into the national immunization program with a 23-valent pneumococcal polysaccharide vaccine in May 2013.ObjectiveThe aim of this study was to assess the performance of the program in increasing the vaccine coverage rate and maintaining stable vaccine supply and safe vaccination during the 20 months of the program.MethodsWe qualitatively and quantitatively analyzed the process of introducing and the outcomes of the program in terms of the systematic organization, efficiency, and stability at the national level.ResultsA staggered introduction during the first year utilizing the public sector, with a target coverage of 60%, was implemented based on the public demand for an elderly pneumococcal vaccination, vaccine supply capacity, vaccine delivery capacity, safety, and sustainability. During the 20-month program period, the pneumococcal vaccine coverage rate among the population aged ≥65 years increased from 5.0% to 57.3% without a noticeable vaccine shortage or safety issues. A web-based integrated immunization information system, which includes the immunization registry, vaccine supply chain management, and surveillance of adverse events following immunization, reduced programmatic errors and harmonized the overall performance of the program.ConclusionIntroduction of an elderly pneumococcal vaccination in the national immunization program based on strong government commitment, meticulous preparation, financial support, and the pre-existing public health infrastructure resulted in an efficient, stable, and sustainable increase in vaccination coverage.     

The shrinking world of girls at puberty: Violence and gender-divergent access to the public sphere among adolescents in South Africa

Participatory mapping was undertaken with single-sex groups of grade 5 and grade 8–9 children in KwaZulu-Natal. Relative to grade 5 students, wide gender divergence in access to the public sphere was found at grade 8–9. With puberty, girls' worlds shrink, while boys' expand. At grade 5, female-defined community areas were equal or larger in size than those of males. Community area mapped by urban grade 8–9 girls, however, was only one-third that of male classmates and two-fifths that of grade 5 girls. Conversely, community area mapped by grade 8–9 boys was twice that of grade 5 boys. Similar differences emerged in the rural site. No female group rated a single community space as more than ‘somewhat safe’. Although curtailed spatial access is intended to protect girls, grade 8–9 girls reported most places in their small navigable areas as very unsafe. Expanded geographies of grade 8–9 boys contained a mix of safe and unsafe places. Reducing girls' access to the public sphere does not increase their perceived safety, but may instead limit their access to opportunities for human development. The findings emphasise the need for better violence prevention programming for very young adolescents.     

Strengthening of causality assessment of adverse events following immunization in the WHO South East Asia and Western Pacific regions: Lessons from the 2014 SEAR inter-country workshop

BackgroundPoorly managed AEFI undermine immunization programs. Improved surveillance in SEAR countries means more AEFIs but management varies. SEAR brought countries together to share AEFI experiences, and learn more about causality assessment.MethodsThree day 10 country workshop (9 SEAR; 1 WPR). Participants outlined county AEFI experiences, undertook causality assessment for 8 AEFIs using WHO methodology, critiqued the process by questionnaire and had a discussion.ResultsAll 10 valued AEFI monitoring and causality assessment, and praised the opportunity to share experiences. Participants determined a range of AEFI and causality assessment needs in SEAR such as adapting WHO Algorithm, CIOMS/Brighton definitions, WHO verbal autopsy to fit context, requesting a practical guide – AEFI definition, time interval, rates of AEFI for different vaccines and evidence for vaccine related causes of death under 24 h.ConclusionsLMIC need WHO AEFI tools adapted to better fit LMIC. Learning from each other builds capacity. Sharing AEFI experiences, case reviews help LMIC improve practices.     

Social media and HPV vaccination: Unsolicited public comments on a Facebook post by the Western Cape Department of Health provide insights into determinants of vaccine hesitancy in South Africa

On the 4 February 2019, the Western Cape Department of Health’s Facebook page announced the implementation of a school-based vaccination campaign aimed to administer the first doses of human papillomavirus (HPV) vaccine in public schools to Grade 4 girls who are nine years old. This announcement was met with a flurry of social media responses posted on the campaign’s Facebook page. This study identifies determinants of vaccine hesitancy amongst responses provided by social media users to this post. On 8 March 2019, we conducted a qualitative study including all 157 comments to the Facebook post. The post had 659 ‘emotion’ reactions: 574 “likes”, 62 “loves”, 21 “angry faces”, 2 “laughs”, 2 “wows” and 1 “sad face”. An overwhelming majority (636/659 i.e. 97%) of reactions were favourable to the HPV vaccination campaign. Out of the 157 comments, we judged 52 (33%) of them to be ‘hesitant’, suggesting that people with negative reactions though few in number, were more likely to be vocal deniers. Concern around the safety of HPV vaccines including effects on reproductive health was the most common theme identified. Other emerging themes included: risk of cervical cancer perceived as being low, issues around consent, concerns that girls are being used for research, questionable vaccine effectiveness, use of the school-based strategy for the campaign, risk-benefits calculations of HPV vaccination and constraints such as stock-outs. Knowing someone who had been affected or being at risk of cervical cancer, having knowledge about the causes of cervical cancer, confidence in the effectiveness and safety of the vaccine, knowing the vaccine was being used in high income settings, and having strong recommendations from the World Health Organisation and key actors seemed to increase the willingness to accept the vaccine. The magnitude and causes of HPV vaccine hesitancy need to be investigated to ensure the success of this programme.     

Why equity in health and in access to health care are elusive: Insights from Canada and South Africa

Health and access to health care vary strikingly across the globe, and debates about this have been pervasive and controversial. Some comparative data in Canada and South Africa illustrate the complexity of achieving greater equity anywhere, even in a wealthy country like Canada. Potential bi-directional lessons relevant both to local and global public health are identified. Both countries should consider the implications of lost opportunity costs associated with lack of explicit resource allocation policies. While National Health Insurance is attractive politically, Canada's example cannot be fully emulated in South Africa. Short- and medium-term attempts to improve equity in middle-income countries should focus on equitable access to insurance to cover primary health care and on making more use of nurse practitioners and community health workers. In the longer-term, attention is needed to the economic and political power structures that influence health and health care and that ignore the social and societal determinants of sustainable good health locally and globally. This long-term vision of health is needed globally to achieve improvements in individual and population health in a century characterised by limits to economic growth, widening disparities, continuing conflict and migration on a large scale and multiple adverse impacts of climate change.     

Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects

After a decline in enthusiasm for national community health worker (CHW) programmes in the 1980s, these have re-emerged globally, particularly in the context of HIV. This paper examines the case of South Africa, where there has been rapid growth of a range of lay workers (home-based carers, lay counsellors, DOT supporters etc.) principally in response to an expansion in budgets and programmes for HIV, most recently the rollout of antiretroviral therapy (ART). In 2004, the term community health worker was introduced as the umbrella concept for all the community/lay workers in the health sector, and a national CHW Policy Framework was adopted. We summarize the key features of the emerging national CHW programme in South Africa, which include amongst others, their integration into a national public works programme and the use of non-governmental organizations as intermediaries. We then report on experiences in one Province, Free State. Over a period of 2 years (2004--06), we made serial visits on three occasions to the first 16 primary health care facilities in this Province providing comprehensive HIV services, including ART. At each of these visits, we did inventories of CHW numbers and training, and on two occasions conducted facility-based group interviews with CHWs (involving a total of 231 and 182 participants, respectively). We also interviewed clinic nurses tasked with supervising CHWs. From this evaluation we concluded that there is a significant CHW presence in the South African health system. This infrastructure, however, shares many of the managerial challenges (stability, recognition, volunteer vs. worker, relationships with professionals) associated with previous national CHW programmes, and we discuss prospects for sustainability in the light of the new policy context.     

Short-term physical and emotional health outcomes of public sector ART in the Free State province of South Africa

INTRODUCTION: In order to assess the health outcomes of the South African public sector antiretroviral treatment (ART) programme, it is important to gain a better understanding of the complex relationship between ART and the multidimensional construct quality of life (QoL). Because of the gap between supply and demand, equity issues arise concerning the provisioning of ART. OBJECTIVE: The aim of this paper is to examine how and to what extent public sector ART is related to the physical and emotional health of people living with HIV/AIDS (PLWHA). METHODS: The stratified random sample consisted of 371 AIDS patients on ART or medically certified for ART, but still awaiting treatment. A model of the relationships between patient characteristics (age and gender) and socio-economic position (educational level, income, type of dwelling, number of rooms), ART duration, and physical and emotional QoL was tested using structural equation modelling. RESULTS: Patients with a higher personal income (beta = .19, P < .05) and a larger dwelling (beta = .45, P < .01) were significantly more likely to enter the programme at this early stage. The model showed that the initial months of ART have been associated with significant improvements in the physical QoL (beta = .21, P < .01). Furthermore, patients on ART reported significantly higher levels of emotional well-being than patients awaiting treatment (beta = .10, P < .01). Finally, the results indicate that ART is not only directly associated with emotional QoL, but is also indirectly associated with emotional QoL via the mediating variable physical QoL (beta = .30, P < .01). CONCLUSIONS: The study suggests that the poorest of the poor are not the first beneficiaries of the public programme. Most importantly, the present findings demonstrate the positive physical and emotional health outcomes of the first 6 months of ART in the Free State, South Africa.     

Using multilevel models to evaluate the influence of contextual factors on HIV/AIDS,sexually transmitted infections,and risky sexual behavior in sub-Saharan Africa: a systematic review

Purpose

To describe the use of multilevel models (MLMs) in evaluating the influence of contextual factors on HIV/AIDS, sexually transmitted infections (STIs), and risky sexual behavior (RSB) in sub-Saharan Africa.

Knowledge,attitudes and perspective on adverse drug reaction reporting in a public sector hospital in South Africa: baseline analysis

Objective: Adverse drug reactions (ADRs) can cause significant harm in patients; however, ADRs are under-reported in many countries, including South Africa, where evidence of a pharmacovigilance (PV) system to monitor and manage ADRs is a requirement for compliance with norms and standards for quality healthcare delivery. We conducted an analysis amongst health care professionals (HCPs) at Sebokeng Hospital to assess the situation there and make recommendations.

Methods: Data were collected using a structured self-administered questionnaire, targeting all medical practitioners, nurses, pharmacists and pharmacist assistants in the hospital. Current procedures for reporting of ADRs were documented. Records were reviewed to determine the number of ADR reports submitted for the 18-month period prior to the study. Data were analysed with SAS. Ethical clearance was obtained.

Results: The questionnaire was completed by 132 HCPs (nurses: 58.3%; medical practitioners: 23.5%; pharmacist assistants: 11.4%; pharmacists: 6.8%). The vast majority indicated ADR reporting is necessary (96.2%) and their professional obligation (89.4%). Only 18.9% were aware of an existing PV system in the hospital, 15.2% had an ADR form available and 18.9% knew to whom the form should be submitted. The vast majority had never reported an ADR, had never received training in PV, but wanted training on ADR reporting. Factors discouraging ADR reporting included not knowing how to report them (53.8%), lack of time (37.1%), additional work load (22.0%), uncertainty about the outcome of reporting (32.6%), and lack of confidence to discuss ADRs with colleagues (22.0%). Only 2.3% knew how many ADRs were reported, that ADRs are discussed by a committee (6.1%) and that internal feedback is received on reported ADRs (6.1%).

Conclusion: There is an extensive need in Sebokeng Hospital for training on ADR reporting and implementation of systems to facilitate relevant processes; a need which may also exist in other public hospitals in South Africa.     

A comparative analysis of the use of maternal health services between teenagers and older mothers in sub-Saharan Africa: evidence from Demographic and Health Surveys (DHS)

This paper uses Demographic and Health Surveys data from 21 countries in sub-Saharan Africa to examine the use of maternal health services by teenagers. A comparison of maternal health care between teenagers and older women, based on bivariate analysis shows little variation in maternal health care by age. However, after controlling for the effect of background factors such as parity, premarital births, educational attainment and urban/rural residence in a multivariate analysis, there is evidence that teenagers have poorer maternal health care than older women with similar background characteristics. The results from multilevel logistic models applied to pooled data across countries show that teenagers are generally more likely to receive inadequate antenatal care and have non-professional deliveries. An examination of country-level variations shows significant differences in the levels of maternal health care across countries. However, there is no evidence of significant variations across countries in the observed patterns of maternal health care by maternal age. This suggests that the observed patterns by maternal age are generalizable across the sub-Saharan Africa region.     

Methods for evaluating the impact of vertical programs on health systems: protocol for a study on the impact of the global polio eradication initiative on strengthening routine immunization and primary health care

ABSTRACT: BACKGROUND: The impact of vertical programs on health systems is a much-debated topic, and more evidence on this complex relationship is needed. This article describes a research protocol developed to assess the relationship between the Global Polio Eradication Initiative, routine immunization, and primary health care in multiple settings. METHODS: This protocol was designed as a combination of quantitative and qualitative research methods, making use of comparative ethnographies. The study evaluates the impact of the Global Polio Eradication Initiative on routine immunization and primary health care by: (a) combining quantitative and qualitative work into one coherent study design; (b) using purposively selected qualitative case studies to systematically evaluate the impact of key contextual variables; and (c) making extensive use of the method of participant observation to create comparative ethnographies of the impact of a single vertical program administered in varied contexts. DISCUSSION: The study design has four major benefits: (1) the careful selection of a range of qualitative case studies allowed for systematic comparison; (2) the use of participant observation yielded important insights on how policy is put into practice; (3) results from our quantitative analysis could be explained by results from qualitative work; and (4) this research protocol can inform the creation of actionable recommendations. Here, recommendations for how to overcome potential challenges in carrying out such research are presented. This study illustrates the utility of mixed-methods research designs in which qualitative data are not just used to embellish quantitative results, but are an integral component of the analysis.     

Factors limiting data quality in the expanded programme on immunization in low and middle-income countries: A scoping review

Few public health interventions can match the immense achievements of immunization in terms of mortality and morbidity reduction. However, progress in reaching global coverage goals and achieving universal immunization coverage have stalled; with key stakeholders concerned about the accuracy of reported coverage figures. Incomplete and incorrect data has made it challenging to obtain an accurate overview of immunization coverage, particularly in low- and middle-income countries (LMIC).To date, only one literature review concerning immunization data quality exists. However, it only included articles from Gavi-eligible countries, did not go deep into the characteristics of the data quality problems, and used a narrow ‘data quality’ definition. This scoping review builds upon that work; exploring the “state of data quality” in LMIC, factors affecting data quality in these settings and potential means to improve it.Only a small volume of literature addressing immunization data quality in LMIC was found and definitions of ‘data quality’ varied widely. Data quality was, on the whole, considered poor in the articles included. Coverage numerators were seen to be inflated for official reports and denominators were inaccurate and infrequently adjusted. Numerous factors related to these deficiencies were reported, including health information system fragmentation, overreliance on targets and poor data management processes. Factors associated with health workers were noted most frequently. Authors suggested that data quality could be improved by ensuring proper data collection tools, increasing workers’ capacities and motivation through training and supervision, whilst also ensuring adequate and timely feedback on the data collected.The findings of this scoping review can serve as the basis to identify and address barriers to good quality immunization data in LMICs. Overcoming said barriers is essential if immunization’s historic successes are to continue.     

“Conditional scholarships” for HIV/AIDS health workers: Educating and retaining the workforce to provide antiretroviral treatment in sub-Saharan Africa

Without large increases in the number of health workers to treat HIV/AIDS (HAHW) many countries in sub-Saharan Africa will be unable to achieve universal coverage with antiretroviral treatment (ART), leading to large numbers of avoidable deaths among people living with HIV/AIDS. We conduct a cost-benefit analysis of a health care education scholarship that is conditional on the recipient committing to work for several years after graduation delivering ART in sub-Saharan Africa. Such a scholarship could address two of the main reasons for the low numbers of health workers in sub-Saharan Africa: low education rates and high emigration rates. We use Markov Monte Carlo microsimulation to estimate the expected net present value (eNPV) of “conditional scholarships” in sub-Saharan Africa. The scholarships are highly eNPV-positive under a wide range of assumptions. Conditional scholarships for a HAHW team sufficient to provide ART for 500 patients have an eNPV of 1.24 million year-2000 US dollars, assuming that the scholarship recipients are in addition to the health workers who would have been educated without scholarships and that the scholarships reduce annual HAHW emigration probabilities from 15% to 5% for five years. The eNPV of the education effect of the scholarships is larger than eNPV of the migration effect. Policy makers should consider implementing “conditional scholarships” for HAHW, especially in countries where health worker education capacity is currently underutilized or can be rapidly expanded.     

Medical circumcision and manhood initiation rituals in the Eastern Cape,South Africa: a post intervention evaluation

The objectives of this study were first, to report the adverse events reported following male circumcision performed by medical professionals after a one‐day training workshop; second, to report on the attitudes towards, beliefs surrounding and experiences regarding circumcision and initiation; and third, to assess the HIV‐risk behaviour of young men attending initiation schools post medical circumcision. Initiates who had been medically circumcised by trained healthcare providers were examined and interviewed on the seventh day after circumcision and, in addition, focus‐group discussions were conducted with initiates. Results indicate that of the 78 initiates physically examined on the seventh day after circumcision by a trained clinical nurse, seven (9%) adverse events (complications) were found. Initiates reported mixed attitudes towards combining medical circumcision with traditional initiation. The majority of the initiates (70%) felt that they could be stigmatized as a result of choosing medical rather than traditional circumcision and 20% thought that the relationship between medical and traditionally circumcised men was hostile. Prior to circumcision, most initiates (92%) had been sexually active and had engaged in HIV‐risk behaviour. Focus‐group discussions revealed that sexually active initiates, when asked about sex after circumcision, indicated they wished to abstain for a short period before resuming sexual activities with intended condom use being high. Findings are promising for efforts to up‐scale integrated medical circumcision alongside traditional initiation into manhood.     

Cumulative risk and AIDS-orphanhood: Interactions of stigma,bullying and poverty on child mental health in South Africa

Research shows that AIDS-orphaned children are more likely to experience clinical-range psychological problems. Little is known about possible interactions between factors mediating these high distress levels. We assessed how food insecurity, bullying, and AIDS-related stigma interacted with each other and with likelihood of experiencing clinical-range disorder. In South Africa, 1025 adolescents completed standardised measures of depression, anxiety and post-traumatic stress. 52 potential mediators were measured, including AIDS-orphanhood status. Logistic regressions and hierarchical log-linear modelling were used to identify interactions among significant risk factors. Food insecurity, stigma and bullying all independently increased likelihood of disorder. Poverty and stigma were found to interact strongly, and with both present, likelihood of disorder rose from 19% to 83%. Similarly, bullying interacted with AIDS-orphanhood status, and with both present, likelihood of disorder rose from 12% to 76%. Approaches to alleviating psychological distress amongst AIDS-affected children must address cumulative risk effects.