One size does not fit all: local determinants of measles vaccination in four districts of Pakistan

Background

Rates of childhood vaccination in Pakistan remain low.There is continuing debate about the role of consumer and service factors in determining levels of vaccination in developing countries.

Methods

In a stratified random cluster sample of census enumeration areas across four districts in Pakistan, household interviews about vaccination of children and potentially related factors with 10,423 mothers of 14,542 children preceded discussion of findings in separate male and female focus groups. Logistic regression analyses helped to clarify local determinants of measles vaccination.

Results

Across the four districts, from 17% to 61% of mothers had formal education and 50% to 86% of children aged 12-23 months had received measles vaccination. Children were more likely to receive measles vaccination if the household was less vulnerable, if their mother had any formal education, if she knew at least one vaccine preventable disease, and if she had not heard of any bad effects of vaccination. Discussing vaccinations in the family was strongly associated with vaccination. In rural areas, living within 5 km of a vaccination facility or in a community visited by a vaccination team were associated with vaccination, as was the mother receiving information about vaccinations from a visiting lady health worker. Focus groups confirmed personal and service delivery obstacles to vaccination, in particular cost and poor access to vaccination services. Despite common factors, the pattern of variables related to measles vaccination differed between and within districts.

Conclusions

Vaccination coverage varies from district to district in Pakistan and between urban and rural areas in any district. Common factors are associated with vaccination, but their relative importance varies between locations. Good local information about vaccination rates and associated variables is important to allow effective and equitable planning of services.

     

Verantwortung des Betriebsmediziners im Rahmen der Gesundheitsförderung

Background

Many adults in Germany do not receive immunizations as recommended. False assumptions about vaccinations and the risk of infectious diseases are important reasons why people fail to receive recommended immunizations.

Aim

Our aim was to provide new possibilities to improve vaccination rates among adults. We directed special attention to some newsworthy infectious diseases (e.g. measles, pertussis).

Results

Owing to their special range of responsibilities and their numerous medical attendances, occupational health physicians are in a position to improve the immunization rates of adults as well as to collect epidemiologic data of this broad age group.

Conclusions

The use of a mobile cart vaccination program in the workplace might increase vaccination rates.

     

Knowledge synthesis of benefits and adverse effects of measles vaccination: the Lasbela balance sheet

Background

In preparation for a cluster-randomized controlled trial of a community intervention to increase the demand for measles vaccination in Lasbela district of Pakistan, a balance sheet summarized published evidence on benefits and possible adverse effects of measles vaccination.

Methods

The balance sheet listed: 1) major health conditions associated with measles; 2) the risk among the unvaccinated who contract measles; 3) the risk among the vaccinated; 4) the risk difference between vaccinated and unvaccinated; and 5) the likely net gain from vaccination for each condition.

Results

Two models revealed very different projections of net gain from measles vaccine. A Lasbela-specific combination of low period prevalence of measles among the unvaccinated, medium vaccination coverage and low vaccine efficacy rate, as revealed by the baseline survey, resulted in less-than-expected gains attributable to vaccination. Modelled on estimates where the vaccine had greater efficacy, the gains from vaccination would be more substantial.

Conclusion

Specific local conditions probably explain the low rates among the unvaccinated while the high vaccine failure rate is likely due to weaknesses in the vaccination delivery system. Community perception of these realities may have had some role in household decisions about whether to vaccinate, although the major discouraging factor was inadequate access. The balance sheet may be useful as a communication tool in other circumstances, applied to up-to-date local evidence.

     

Description of a large measles epidemic in Democratic Republic of Congo, 2010–2013

Background

Although measles mortality has declined dramatically in Sub-Saharan Africa, measles remains a major public health problem in countries like the Democratic Republic of Congo (DRC). Here, we describe the large measles epidemic that occurred in the Democratic Republic of Congo between 2010 and 2013 using data from the national surveillance system as well as vaccine coverage surveys to provide a snapshot of the epidemiology of measles in DRC.

Methods

Standardized national surveillance data were used to describe measles cases from 2010 to 2013. Attack rates and case fatality ratios were calculated and the temporal and spatial evolution of the epidemic described. Data on laboratory confirmation and vaccination coverage surveys as a part of routine program monitoring are also presented.

Findings

Between week 1 of 2010 and week 45 of 2013, a total of 294,455 cases and 5,045 deaths were reported. The cumulative attack rate (AR) was 0.4%. The Case Fatality Ratio (CFR) was 1.7% among cases reported in health structures through national surveillance. A total of 186,178 cases (63%) were under 5 years old, representing an estimated AR of 1.4% in this age group. Following the first mass vaccination campaigns, weekly reported cases decreased by 21.5%. Results of post-vaccination campaign coverage surveys indicated sub-optimal (under 95%) vaccination coverage among children surveyed.

Conclusions

The data reported here highlight the need to seek additional means to reinforce routine immunization as well as ensure the timely implementation of Supplementary Immunization Activities to prevent large and repeated measles epidemics in DRC. Although reactive campaigns were conducted in response to the epidemic, strategies to ensure that children are vaccinated in the routine system remains the foundation of measles control.

     

Prevalence and factors associated with incomplete immunization of children (12–23 months) in Kwabre East District,Ashanti Region,Ghana

Background

Childhood immunization is one of the most cost effective health interventions but its rate has been declining recently in Ghana. Information on immunization coverage and determinants is needed to improve immunization programmes. The objective of this study was to determine the prevalence and factors associated with incomplete immunization of children (12–23 months) in Kwabre East District, Ghana.

Methods

A cross-sectional, community-based survey involving 322 children and their mothers was carried out. Data were collected on socio-demographic characteristics of mothers, childhood immunization history and mothers’ knowledge and practices of immunization using a structured questionnaire. Children were classified as incompletely immunized if they failed to receive at least one of 8 vaccine doses: - one dose of Bacillus Calmette–Guérin (BCG), 3 doses each of pentavalent, 3 doses of polio and one dose of measles per WHO/UNICEF definition. Chi-square and logistic regression analyses were used to identify the factors associated with incomplete immunisation.

Results

The prevalence of incomplete immunization was low (15.5%) suggesting high immunisation coverage but the coverage of the second measles dose, taken at 18 months of age, was the lowest (23.9%). Most of the mothers knew the importance of immunisation (95.7%) and at least one vaccine-preventable disease or symptom (84.9%). Two factors associated with incomplete immunisation in bivariate analyses (community of residence, and mother’s knowledge of number of oral polio vaccines given to children) were no longer significant in a logistic regression model. Compared to children in Aboaso, children in Gyamfi Wonoo (AOR?=?1.81, 95% CI?=?0.80–4.08), Mamponteng (Bonwunu) (AOR?=?0.59, 95% CI?=?0.24–1.48) and Mamponteng (Town) (AOR?=?0.63, 95% CI?=?0.26–1.55) had similar odds of incomplete immunisation. Similarly, mother’s lack of knowledge of the number of doses of polio vaccine given to children had no effect on the odds of incomplete immunisation (AOR?=?0.53, 95% CI?=?0.22–1.26).

Conclusions

Immunization coverage is high in the Kwabre East district but very few children received the second measles dose. None of the maternal and child factors assessed is associated with immunisation coverage. Further research is needed to identify the determinants of immunisation coverage and the reasons for the low uptake of second measles dose in the study area.

     

Wissen und Einstellungen zur Masernimpfung bei Medizinstudierenden

Background

Insufficient immunization rates among health care personnel and general public cause recurring measles outbreaks. To achieve higher immunization rates, a profound knowledge and positive attitude concerning vaccinations are needed, as well as confident vaccination consultations provided by a treating physician. As medical students in future are main contact persons for patients regarding vaccination, we analysed their attitudes towards and the knowledge about measles immunization in Munich and Dresden in order to take into account possible influences of different vaccination policies.

Materials and methods

In summer term 2015, we invited medical students in their last three years of the studies (5th–10th semester) during compulsory and voluntary courses at the Technische Universität München (TUM) and Technische Universität Dresden (TUD) to participate in our study.

Results

In all, 508 students of the TUM and 216 students of the TUD could be included in our study. On average, 46.7% of the knowledge items were answered correctly at both study sites. The age of the participants seemed to have the strongest influence on the knowledge. The attitudes towards measles vaccinations were very positive at both study sites (93.1% approval on average). Neither the study site, nor the state of origin of the participants, or a previous medical education showed a significant influence on the attitude towards measles vaccination.

Conclusions

The knowledge of the study participants seemed to be insufficient, although their attitudes towards measles vaccination were positive. It is important that medical students are confronted more with the topic vaccination during their studies.

     

Evidence-based discussion increases childhood vaccination uptake: a randomised cluster controlled trial of knowledge translation in Pakistan

Background

Childhood vaccination rates are low in Lasbela, one of the poorest districts in Pakistan's Balochistan province. This randomised cluster controlled trial tested the effect on uptake of informed discussion of vaccination costs and benefits, without relying on improved health services.

Methods

Following a baseline survey of randomly selected representative census enumeration areas, a computer generated random number sequence assigned 18 intervention and 14 control clusters. The intervention comprised three structured discussions separately with male and female groups in each cluster. The first discussion shared findings about vaccine uptake from the baseline study; the second focussed on the costs and benefits of childhood vaccination; the third focussed on local action plans. Field teams encouraged the group participants to spread the dialogue to households in their communities. Both intervention and control clusters received a district-wide health promotion programme emphasizing household hygiene. Interviewers in the household surveys were blind of intervention status of different clusters. A follow-up survey after one year measured impact of the intervention on uptake of measles and full DPT vaccinations of children aged 12-23 months, as reported by the mother or caregiver.

Results

In the follow-up survey, measles and DPT vaccination uptake among children aged 12-23 months (536 in intervention clusters, 422 in control clusters) was significantly higher in intervention than in control clusters, where uptake fell over the intervention period. Adjusting for baseline differences between intervention and control clusters with generalized estimating equations, the intervention doubled the odds of measles vaccination in the intervention communities (OR 2.20, 95% CI 1.24-3.88). It trebled the odds of full DPT vaccination (OR 3.36, 95% CI 2.03-5.56).

Conclusion

The relatively low cost knowledge translation intervention significantly increased vaccine uptake, without relying on improved services, in a poor district with limited access to services. This could have wide relevance in increasing coverage in developing countries.

Trial registration

ISRCTN12421731.

     

Equity and vaccine uptake: a cross-sectional study of measles vaccination in Lasbela District,Pakistan

Background

Achieving equity means increased uptake of health services for those who need it most. But the poorest families continue to have the poorest service. In Pakistan, large numbers of children do not access vaccination against measles despite the national government's effort to achieve universal coverage.

Methods

A cross-sectional study of a random sample of 23 rural and 9 urban communities in the Lasbela district of south Pakistan, explored knowledge, attitudes and discussion around measles vaccination. Several socioeconomic variables allowed examination of the role of inequities in vaccination uptake; 2479 mothers provided information about 4007 children aged 10 to 59 months. A Mantel-Haenszel stratification analysis, with and without adjustment for clustering, clarified determinants of measles vaccination in urban and rural areas.

Results

A high proportion of mothers had appropriate knowledge of and positive attitudes to vaccination; many discussed vaccination, but only one half of children aged 10-59 months accessed vaccination. In urban areas, having an educated mother, discussing vaccinations, having correct knowledge about vaccinations, living in a community with a government vaccination facility within 5 km, and living in houses with better roofs were associated with vaccination uptake after adjusting for the effect of each of these variables and for clustering; maternal education was an equity factor even among those with good access. In rural areas, the combination of roof quality and access (vaccination post within 5 km) along with discussion about vaccines and knowledge about vaccines had an effect on uptake.

Conclusion

Stagnating rates of vaccination coverage may be related to increasing inequities. A hopeful finding is that discussion about vaccines and knowledge about vaccines had a positive effect that was independent of the negative effect of inequity - in both urban and rural areas. At least as a short term strategy, there seems to be reason to expect an intervention increasing knowledge and discussion about vaccination in this district might increase uptake.

     

Was there a disparity in age appropriate infant immunization uptake in the theatre of war in the North of Sri Lanka at the height of the hostilities?: a cross-sectional study in resettled areas in the Kilinochchi district

Background

It was long speculated that there could be under-immunized pockets in the war affected Northern part of Sri Lanka relative to other areas. With the cessation of hostilities following the military suppression of the rebellion, opportunities have arisen to appraise the immunization status of children in areas of re-settlement in former war ravaged districts.

Methods

We conducted a cross-sectional study to describe the coverage and age appropriateness of infant vaccinations in a former conflict district during the phase of re-settlement. The target population comprised all children of re-settled families in the age group of 12 – 23 months in the district. We selected a study sample of 300 children from among the target population using the WHO’s 30 cluster EPI survey method. Trained surveyors collected data using a structured checklist. The infant vaccination status was ascertained by reviewing vaccination records in the Child Health Development Record or any other alternative documentary evidence.

Results

The survey revealed that the proportion of fully vaccinated children in the district was 91%. For individual vaccines, it ranged from 92% (measles) to 100% (BCG, DPT/OPV1). However, the age appropriateness of vaccination was less than 50% for all antigens except for BCG (94%). The maximum number of days of delay of vaccinations ranged from 21 days for BCG to 253 days for measles. Age appropriate vaccination rates significantly differed for DPT/OPV1-3 and measles during the conflict and post-conflict stages while it did not for the BCG. Age appropriate vaccination rates were significantly higher for DPT/OPV1-3 during the conflict while for the measles it was higher in the post conflict stage.

Conclusions

Though the vaccination coverage for infant vaccines in the war affected Kilinochchi district was similar to other districts in the country, it masked a disparity in terms of low age-appropriateness of infant immunizations given in field settings. This finding underscores the need for investigation of underlying reasons and introduction of remedial measures in the stage of restoring Primary Health Care services in the ex-conflict zone.

     

Available studies fail to provide strong evidence of increased risk of diarrhea mortality due to measles in the period 4–26 weeks after measles rash onset

Background

Measles vaccination effectiveness studies showed dramatic decreases in all-cause mortality in excess of what would be expected from the prevention of measles disease alone. This invited speculation that measles infection may increase the risk of diarrhea morbidity and mortality subsequent to the acute phase of the disease. The aim of the present systematic review is to summarize the existing evidence in the publically available literature pertaining to the putative causal link between measles and diarrhea in the period 4–26 weeks following measles rash onset.

Methods

We searched the PubMed, Embase, Open Grey and Grey Literature Report databases for relevant literature using broad search terms. Prospective, retrospective and case-control studies in low- and middle-income countries involving children under five wherein relevant evidence were presented were included. Data were extracted from the articles and summarized.

Results

Fifty abstracts retrieved through the database searches met the initial screening criteria. Twelve additional documents were identified by review of the references of the documents found in the initial searches. Six documents representing five unique studies that presented evidence relevant to the research question were found. Four of the included studies took place in Bangladesh. One of the included studies took place in Sudan. Some measles vaccine effectiveness studies show lower diarrhea morbidity and mortality among the vaccinated. However, children who received vaccine may have differed in important ways from children who did not, such as health service utilization. Additionally, cohort studies following unvaccinated children showed no difference in diarrhea morbidity and mortality between cases and controls more than 4 weeks after measles rash onset. One study showed some evidence that severe measles may predispose children to gastroenteritis, but was not able to show a corresponding increase in the risk of diarrhea mortality.

Conclusions

The available evidence suggests that the risk of measles-associated diarrhea mortality is largely limited to the 5-week period 1 week prior to and 4 weeks after measles rash onset, and that there is no increased risk of diarrhea mortality in the longer-term caused by measles.

     

The Role of Physician Recommendations and Public Policy in Human Papillomavirus Vaccinations

Background

Immunization rates for human papillomavirus (HPV) infections remain low among teenagers despite strong evidence of the effectiveness of vaccines. Physician recommendations of the vaccine are far from universal. Several states have enacted policies that mandate HPV vaccination or distribute educational materials.

Objectives

To provide policy makers, physicians, and researchers information on the relative importance of physician recommendations and early state-level policies to promote HPV vaccinations among targeted age groups.

Methods

We first use probit models to determine the strongest correlates of immunization in a nationally representative US sample of teenagers. We then use instrumental variable probit models to determine the direct role that physician recommendations play in vaccination using plausibly exogenous physician encounters that are likely not the result of more health-conscious parents seeking out information on the vaccine.

Results

We show that children in the targeted age range who are more likely to encounter physicians for reasons other than seeking out the vaccine, such as through mandatory wellness exams or previous asthma diagnoses, are significantly more likely to get the vaccine. There is no consistent evidence that the state policies we analyze have been effective.

Conclusion

Encouraging recommendations by physicians may be the most effective path toward increasing HPV vaccination. State-level mandates and policies are yet to exhibit effectiveness.

     

Determinants of parents' reticence toward vaccination in urban areas in Benin (West Africa)

Background

Despite the efforts of health authorities, vaccination coverage of targeted child populations is still poor in many regions. Parents' reticence has been identified as one cause of this situation. However, there is little data to explain the phenomenon that could support decision-making.

Objective

The objective of the study was to uncover the determinants of this reticence toward vaccination among the religious population of the cities of Parakou and Cotonou in Benin.

Methods

This was an exploratory study using a qualitative survey of 12 pastors and 30 faithful from churches that are vaccination-reticent and a control group of the same number of faithful belonging to other churches, all Christian. Individual and group interviews were carried out in the local language using a pre-established and pre-tested guide. The data collected underwent discourse content analysis focused on specific themes.

Results

Analysis of the data reveals an erroneous perception of child vaccination. Those who are reticent say vaccination goes against the will of God, that it is a poison from the "white witch doctor", and that those who vaccinate their children are committing a sin. Members of the control group argued against this, but without conviction. They adhere to the principle of obedience to authority, a biblical precept invoked when the vaccinators oblige them to vaccinate their children. Other factors were identified that could explain the reticence, such as the tactlessness of the vaccinators, parents' previous experiences and false rumours about vaccination.

Conclusion

The reasons for reticence are mainly related to parents' beliefs in religious principles that are sometimes poorly understood. To limit the spread of this phenomenon, more detailed information and negotiation between the health authorities and the pastors of these churches are essential.

Abstract in French

See the full article online for a translation of this abstract in French.

     

Evaluation of immunization coverage within the Expanded Program on Immunization in Kita Circle,Mali: a cross-sectional survey

Background

In 1986, the Government of Mali launched its Expanded Program on Immunization (EPI) with the goal of vaccinating, within five years, 80% of all children under the age of five against six target diseases: diphtheria, tetanus, pertussis, poliomyelitis, tuberculosis, and measles. The Demographic and Health Survey carried out in 2001 revealed that, in Kita Circle, in the Kayes region, only 13% of children aged 12 to 23 months had received all the EPI vaccinations. A priority program was implemented in 2003 by the Regional Health Department in Kayes to improve EPI immunization coverage in this area.

Methods

A cross-sectional survey using Henderson's method (following the method used by the Demographic and Health Surveys) was carried out in July 2006 to determine the level of vaccination coverage among children aged 12 to 23 months in Kita Circle, after implementation of the priority program. Both vaccination cards and mothers' declarations (in cases where the mother cannot make the declaration, it is made by the person responsible for the child) were used to determine coverage.

Results

According to the vaccination cards, 59.9% [CI 95% (54.7-64.8)] of the children were fully vaccinated, while according to the mothers' declarations the rate was 74.1% [CI 95% (69.3-78.4)]. The drop-out rate between DTCP1 and DTCP3 was 5.5%, according to the vaccination cards. The rate of immunization coverage was higher among children whose mothers had received the anti-tetanus vaccine [OR = 2.1, CI 95% (1.44-3.28)]. However, our study found no difference associated with parents' knowledge about EPI diseases, distance from the health centre, or socio-economic status. Lack of information was one reason given for children not being vaccinated against the six EPI diseases.

Conclusion

Three years after the implementation of the priority program (which included decentralization, the active search for missing children, and deployment of health personnel, material and financial resources), our evaluation of the vaccination coverage rates shows that there is improvement in the EPI immunization coverage rate in Kita Circle. The design of our study did not, however, enable us to determine the extent to which different aspects of the program contributed to this increase in coverage. Efforts should nevertheless be continued, in order to reach the goal of 80% immunization coverage.

Abstract in French

See the full article online for a translation of this abstract in French.

     

Cardiovascular disease risk factors among children of different socioeconomic status in Istanbul,Turkey: Directions for public health and nutrition policy

Objectives

The aim of the current study was to examine the influence of socioeconomic status (SES) on physiological (lipid profile, obesity indices) and behavioral (dietary habits, physical activity) cardiovascular disease (CVD) risk factors among primary schoolchildren in Istanbul.

Design

Cross sectional study.

Setting

One private school and two public schools from different SES districts in Istanbul.

Participants

510 randomly selected children aged 12 and 13 years old (257 boys, 253 girls).

Results

The prevalence of overweight (15.2%) and the energy intake (p < 0.001 and p < 0.05 for boys and girls respectively) were found to be higher for the middle/ high SES group for both genders. Regarding biochemical indices, middle/ high SES children had higher values of High Density Lipoprotein-cholesterol (HDL-C) (p < 0.001 and p < 0.05 for boys and girls respectively) and lower values of TC/HDL-C ratio and LDL-C/HDL-C ratio (p < 0.05 and p < 0.001 for boys and girls respectively). This could be attributed to the higher physical activity levels observed for middle/ high SES children (p < 0.001).

Conclusion

The findings of the current study revealed a coexistence of both overweight and higher energy intake in middle/ high SES children, as well as a coexistence of underweight and lower physical activity levels in low SES children. These observations should guide the public health policy in developing appropriate intervention strategies to efficiently tackle these health and social issues early in life.

     

Achieving high uptake of human papillomavirus vaccination in Malaysia through school-based vaccination programme

Background

In 2006, 4 years of planning was started by the Ministry of Health, Malaysia (MOH), to implement the HPV (human papillomavirus) vaccination programme. An inter-agency and multi-sectoral collaborations were developed for Malaysia’s HPV school-based immunisation programme. It was approved for nationwide school base implementation for 13-year-old girls or first year secondary students in 2010. This paper examines how the various strategies used in the implementation over the last 7?years (2010–2016) that unique to Malaysia were successful in achieving optimal coverage of the target population.

Methods

Free vaccination was offered to school girls in secondary school (year seven) in Malaysia, which is usually at the age of 13 in the index year. All recipients of the HPV vaccine were identified through school enrolments obtained from education departments from each district in Malaysia. A total of 242,638 girls aged between 12 to 13?years studying in year seven were approached during the launch of the program in 2010. Approximately 230,000 girls in secondary schools were offered HPV vaccine per year by 646 school health teams throughout the country from 2010 to 2016.

Results

Parental consent for their daughters to receive HPV vaccination at school was very high at 96–98% per year of the programme. Of those who provided consent, over 99% received the first dose each year and 98–99% completed the course per year. Estimated population coverage for the full vaccine course, considering also those not in school, is estimated at 83 to 91% per year. Rates of adverse events reports following HPV vaccination were low at around 2 per 100,000 and the majority was injection site reactions.

Conclusion

A multisectoral and integrated collaborative structure and process ensured that the Malaysia school-based HPV immunisation programme was successful and sustained through the programme design, planning, implementation and monitoring and evaluation. This is a critical factor contributing to the success and sustainability of the school-based HPV immunisation programme with very high coverage.

     

Burden of influenza in Germany: a retrospective claims database analysis for the influenza season 2012/2013

Objective

Seasonal influenza occurs in annual epidemics. The virus can cause severe illness and concomitant diseases with the highest risk for children, the elderly, and individuals with disease dispositions. The study objective is to assess the influenza burden in Germany.

Methods

This retrospective claims data analysis used the Health Risk Institute research database containing anonymized data of 4 million individuals. The study period comprised the influenza season 2012/2013 in which patients with documented influenza were identified. Disease frequency rates were calculated for a population with disease dispositions and a population not at high risk. Disease burden was assessed based on health-services utilization during the influenza season. Vaccine rates were calculated by identifying vaccinations.

Results

We observed 65,826 patients with influenza, resulting in 1,160,646 documented influenza cases after extrapolation. Overall, otitis media and pneumonia was higher in the influenza-infected population compared to the non-influenza-infected population and especially high in children. Hospitalization cost amounted to €87,202,485 with a mean stay of 7 days, and total outpatient costs were €14,947,976. Vaccination rates were <4 % for children and 37 % for patients aged >60.

Conclusions

Seasonal influenza can cause severe outcomes with hospitalizations and excess costs. Especially influenza-infected children are affected by concomitant diseases with higher disease burden. Furthermore, documented vaccination rates are quite low.

     

Portrait of a lengthy vaccination trajectory in Burkina Faso: from cultural acceptance of vaccines to actual immunization

Background

The global recognition of vaccination is strongly related to the fact that it has proved in the past able to dramatically reduce the incidence of certain diseases. Nevertheless, reactions regarding the practice of vaccination still vary among communities, affecting the worldwide vaccination coverage. Numerous studies, conducted from varying perspectives, have focused on explaining this active refusal or resistance to vaccination. Although in some cases low immunization coverage has been well explained by active refusal or resistance to vaccination, little is known about the reasons for low coverage where those reactions are absent or play a minor role, especially outside an epidemic context. This study attempts to explain this situation, which is found in the health district of Nouna in Burkina Faso.

Methods

An in-depth ethnographic study was undertaken in the health district of Nouna in an effort to understand, from an anthropological point of view, the logic behind the parental decision-making process regarding the vaccination or non-vaccination of children, in a context where rejection of, and reservations concerning vaccination are not major obstacles.

Results

Three elements emerged from the analysis: the empirical conceptions of childhood diseases, the perceived efficacy of vaccine and the knowledge of appropriate age for vaccination uptake; the gap between the decision-making process and the actual achievement of vaccination; and the vaccination procedure leading to vaccination uptake in the particular context of the health district of Nouna.

Conclusion

The procedures parents must follow in order to obtain vaccination for their children appear complex and constraining, and on certain points discord with the traditional systems of meaning and idioms of distress related to pregnancy, the prevention of childhood diseases and with the cultural matrix shaping decision-making and behaviour. Attention needs to be directed at certain promotional, logistical and structural elements, and at the procedure that must currently be followed to obtain vaccination for a child during routine vaccination sessions, which are currently limiting the active demand for vaccination.

Abstract in French

See the full article online for a translation of this abstract in French.

     

Ansichten und Erfahrungswerte über die Praxis der Früherkennungs- und Präventionsmaßnahmen von Gebärmutterhalskrebs

Background

The introduction of vaccination against human papillomavirus (HPV) has increased physicians’ and women’s awareness about the prevention of cervical cancer.

Methods

To gain further knowledge about prevention measures against cervical cancer and HPV vaccination in daily practice, 112 physicians were interviewed by means of a standardized questionnaire in an outpatient setting in Mecklenburg–Western Pomerania, Germany.

Results

Regardless of specialisation area, the physicians regarded HPV vaccination positively. They expect not only a reduction in human suffering caused by cervical cancer and its prestages but also, because of less need for therapy and monitoring, a reduction in costs. In addition, they expect increasing awareness of cervical cancer prevention and more regular attendance at cervical cancer screening.

Conclusions

The majority of interviewed physicians showed a positive attitude toward HPV vaccination and do not expect a trade-off between screening and vaccination.

     

Monitoring the performance of the Expanded Program on Immunization: the case of Burkina Faso

Background

The greatest challenge facing expanded programs on immunization in general, and in Burkina Faso in particular, lies in their capacity to achieve and sustain levels of immunization coverage that will ensure effective protection of children. This article aims to demonstrate that full immunization coverage of children, which is the primary indicator for monitoring national immunization programs, is sufficient neither to evaluate their performance adequately, nor to help identify the broad strategies that must be implemented to improve their performance. Other dimensions of performance, notably adherence to the vaccination schedule and the efficacy of the approaches used to reach all the children (targeting) must also be considered.

Methods

The study was carried out using data from surveys carried out in Burkina Faso: the 1993, 1998 and 2003 Demographic and Health Surveys and the 2003 national Survey of Immunization Coverage. Essentially, we described levels of immunization coverage and their trends according to the indicators considered. Performance differences are illustrated by amplitudes and maximum/minimum ratios.

Results

The health regions' performances vary according to whether they are evaluated on the basis of full immunization coverage or vaccination status of children who have not completed their vaccinations. The health regions encompass a variety of realities, and efforts of substantially different intensity would be required to reach all the target populations.

Conclusion

Decision-making can be improved by integrating a tripartite view of performance that includes full immunization coverage, adherence to the vaccination schedule (timely coverage), and the status of children who are not fully vaccinated. With such an approach, interventions can be better targeted. It provides information on the quality and timeliness of vaccination and identifies the efforts required to meet the objectives of full immunization coverage.

Abstract in French

See the full article online for a translation of this abstract in French.

     

Missed opportunities for improving practice performance in adult immunizations: a meta-narrative review of the literature

Background

We sought to characterize how the term “missed opportunities” is reported in the literature in the context of immunization rates and to assess how missed opportunities can be operationalized.

Methods

Peer-reviewed literature searches were conducted in April – May, 2015, to answer: “What methods research studies used to operationalize missed opportunities to vaccinate?” A meta-narrative review methodology was used.

Results

Seven studies met inclusion criteria. The methodologies for quantifying missed opportunities fell into two general categories based on: 1. the number of healthcare encounters per patient without appropriate vaccination services, defined as a number of visits per patient with no vaccination related services (Missed opportunities per patient); 2. vaccination status as “non-vaccinated” among a group of patients who had a healthcare encounter where the vaccination should/could have had happened (Missed opportunities per population).

Conclusions

Our study provided an initial overview of the methods reported in the literature, and concluded that the quantifiable missed opportunity holds promise as a measurable outcome (variable) for research and quality improvement projects aimed to increase adult immunization recommendation and uptake in primary care.