Integrating community outreach into a quality improvement project to promote maternal and child health in Ghana

Quality improvement (QI) is used to promote and strengthen maternal and child health services in middle- and low-income countries. Very little research has examined community-level factors beyond the confines of health facilities that create demand for health services and influence health outcomes. We examined the role of community outreach in the context of Project Fives Alive!, a QI project aimed at improving maternal and under-5 outcomes in Ghana. Qualitative case studies of QI teams across six regions of Ghana were conducted. We analysed the data using narrative and thematic techniques. QI team members used two distinct outreach approaches: community-level outreach, including health promotion and education efforts through group activities and mass media communication; and direct outreach, including one-on-one interpersonal activities between health workers, pregnant women and mothers of children under-5. Specific barriers to community outreach included structural, cultural, and QI team-level factors. QI efforts in both rural and urban settings should consider including context-specific community outreach activities to develop ties with communities and address barriers to health services. Sustaining community outreach as part of QI efforts will require improving infrastructure, strengthening QI teams, and ongoing collaboration with community members.     

安徽省2004-2010年县级妇幼保健机构发展状况分析

目的:了解安徽省县级妇幼保健机构的发展状况,为妇幼保健机构建设与发展提供依据。方法:开展连续多年监测,对全省县级妇幼保健机构2004-2010年度的资源、服务提供及运营情况等进行分析。结果:安徽省县级妇幼保健机构呈现良好的发展态势,但仍存在政府投入不足、人员编制不够、结构不合理、队伍整体素质不高、妇幼保健机构基础建设缺乏规范、机构之间发展不平衡等问题。结论:应进一步强化政府发展妇幼保健事业的责任,增加投入,加强妇幼保健人才队伍建设,制定妇幼保健机构设置标准,加强对妇幼保健机构的考核评估。     

Use of measles supplemental immunization activities (SIAs) as a delivery platform for other maternal and child health interventions: Opportunities and challenges

Measles supplementary immunization activities (SIAs) offer children in countries with weaker immunization delivery systems like India a second opportunity for measles vaccination. They could also provide a platform to deliver additional interventions, but the feasibility and acceptability of including add-ons is uncertain. We surveyed Indian programme officers involved in the current (2010–2012) measles SIAs concerning opportunities and challenges of using SIAs as a delivery platform for other maternal and child health interventions. Respondents felt that an expanded SIA strategy including add-ons could be of great value in improving access and efficiency. They viewed management challenges, logistics, and safety as the most important potential barriers. They proposed that additional interventions be selected using several criteria, of which importance of the health problem, safety, and contribution to health equity figured most prominently. For children, they recommended inclusion of basic interventions to address nutritional deficiencies, diarrhoea and parasites over vaccines. For mothers, micronutrient interventions were highest ranked.     

The effectiveness of maternal pertussis vaccination in protecting newborn infants in Brazil: A case-control study

IntroductionIn 2014, the Brazilian Ministry of Health (MoH) recommended Tdap to pregnant women in response to a significant increase in the incidence of pertussis among infants. The present study assessed the effectiveness of maternal immunization in preventing pertussis in infants.MethodsAn unmatched case-control study was undertaken in São Paulo State, Brazil from February 2015 to July 2016. Cases were infants aged <8 weeks at onset of pertussis reported to the Surveillance System and confirmed by real-time polymerase chain reaction or culture. Four to six healthy infants were selected as controls per case from birth certificates in the Information System on Live Births database. General characteristics and mother’s vaccination status were compared between cases and controls. The vaccine effectiveness (VE) was calculated as 1 – odds ratio (OR). For the adjusted VE, the OR was calculated using logistic regression analysis.ResultsForty-two cases and 248 controls were enrolled in the study. Mothers of 8 cases (19.1%) and 143 controls (57.4%) were vaccinated during pregnancy, resulting in an unadjusted VE of 82.6% (95% confidence interval [CI], 60.8–92.3%). The VE was unchanged after adjusting for maternal age and monthly household income.ConclusionMaternal pertussis vaccination during pregnancy was effective in protecting infants aged <8 weeks from pertussis.     

Effectiveness of a multimodal intervention to increase vaccination in obstetrics/gynecology settings

ObjectiveTo test the effectiveness of a multimodal intervention in obstetrics/gynecology (ob-gyn) clinics to increase uptake of influenza and tetanus-diphtheria-acellular pertussis (Tdap) vaccines in pregnant women and these vaccines plus human papillomavirus (HPV) vaccine in non-pregnant women.MethodsA cluster randomized controlled trial among 9 private ob-gyn practices in Colorado from 9/2011 to 5/2014. The intervention consisted of: designation of immunization champions, staff/provider trainings, assistance with vaccine purchasing/management, identification of eligible patients, standing order implementation, chart review/feedback, and patient education materials. Control practices continued usual care. Primary outcomes were receipt of influenza and Tdap vaccines among pregnant women and these vaccines plus HPV vaccine among non-pregnant women, comparing a Baseline period (Year 0/Year 1) to Year 2, intervention versus control. With an estimated sample size of 32,590 per arm, there would be >80% power to detect a 10% difference between groups.ResultsIn the Baseline period, 27% of pregnant women in both intervention and control practices received influenza vaccine. In Year 2, 29% of pregnant women in intervention practices received influenza vaccine versus 41% in control practices. In the Baseline period, 18% of pregnant women in intervention practices received Tdap vaccine versus 22% in control practices. Both intervention and control practices increased to 51% in Year 2, representing an increase of 33% for intervention practices and 29% for control practices, consistent with a change in Tdap recommendations. Relatively few HPV, influenza or Tdap vaccines (≤6% of eligible patients) were given to non-pregnant patients in either intervention or control practices at any time during the study.ConclusionIn this cluster randomized trial designed to increase vaccination uptake, both intervention and control practices showed improved vaccination of pregnant but not non-pregnant patients. Future work should focus on tailoring evidence-based immunization practices or developing new approaches to specifically fit busy ob-gyn offices.     

Factors associated with the willingness of primary caregivers to avail of a dengue vaccine for their 9 to 14-year-olds in an urban community in the Philippines

To help address the need for preventive measures against dengue fever, a leading cause of child mortality in the Philippines, vaccine trials are ongoing and a tetravalent vaccine (Dengvaxia™, Sanofi Pasteur) has been developed. It is hypothesized that while acceptability would be high among primary caregivers (i.e., parents/guardians), the willingness to have one's child immunized against dengue would be associated with socio-demographic variables, attitudes and knowledge regarding dengue and vaccination, and past experience with dengue. This study aimed to assess the aforementioned factors’ association with primary caregivers’ willingness to avail of a dengue vaccine for their 9 to 14-year-old children in an urban community in the Philippines.A cross-sectional study utilizing interviews was conducted to determine which factors were associated with willingness-to-avail assuming a free vaccine, and a case study utilizing a focus group discussion was employed to capture some underlying reasons for their willingness. Data were analyzed using multiple logistic regression and thematic analysis.Among the 202 study participants, 193 (95.54%) were willing to avail of the vaccine. There was a high probability of vaccine acceptance by primary caregivers (95.54%), with good attitude towards vaccination (≥12/15 points) [aOR 10.62, 90% CI (1.73–26.28)] and large household size (>5) [aOR 9.63, 90% CI (2.04–45.58)] being positively associated with willingness-to-avail, and good knowledge regarding dengue fever [aOR 0.10, 90% CI (0.03–0.74)] and older age (>44 years) [aOR 0.14, 90% CI (0.03–0.61)] being negatively associated.Crude analysis showed that household size, knowledge regarding dengue, and attitude towards vaccination were significantly associated with willingness. Multivariate analysis revealed that these factors and the primary caregiver’s age were associated with willingness. Thematic analysis showed various perceptions regarding dengue and vaccination. Knowing these factors are associated with willingness-to-avail of the vaccine may help in understanding the audience of health promotion projects aimed at increasing immunization coverage.     

Incidence rates of health outcomes of interest among Chinese children exposed to selected vaccines in Yinzhou Electronic Health Records: A population-based retrospective cohort study

IntroductionOral poliovirus vaccine (OPV) and diphtheria-tetanus-acellular pertussis vaccine (DTaP) are widely used in China while Haemophilus influenzae type b vaccines (Hib) and a DTaP, inactivated poliovirus (IPV) and Hib polysaccharide conjugated to tetanus protein (PRP ~ T) combined vaccine (DTaP–IPV//PRP ~ T) have lower coverage. There are limited safety data on these vaccines in Chinese pediatric populations. Methods: To estimate incidence rates (IRs) of health outcomes of interest (HOIs) among children exposed to OPV, DTaP, Hib, and DTaP–IPV//PRP ~ T, we conducted a retrospective cohort study using a population-based electronic health record (EHR) database in Yinzhou district, Ningbo City. Children 0–2 years of age receiving at least one dose of these vaccines between January 1, 2012 and March 31, 2017 were included in the study. Yinzhou EHR database consisted of immunization records and healthcare data of children from hospitals and community health centers in the district. Eight HOIs (i.e., anaphylaxis, febrile seizures, all seizures, asthma, apnea, Kawasaki disease [KD], urticaria/angioedema, Guillain–Barré syndrome [GBS]) were identified using ICD-10 codes. Results: A total of 220,422 eligible children was identified. No cases of apnea, KD, and GBS were observed within 7 days post-vaccination. During 0–7 days post-vaccination for OPV, DTaP, Hib, and DTaP–IPV//PRP ~ T, the IRs of anaphylaxis, febrile seizures, all seizures, urticaria/angioedema and asthma ranged from 0.0 to 50.0, 0.0 to 99.9, 29.1 to 249.8, 297.8 to 949.1, and 992.7 to 2298.2 per 100,000 person-years, respectively, and 0.0 to 0.9, 0.0 to 1.9, 0.6 to 4.6, 5.6 to 17.5, and 18.7 to 42.3 per 100,000 doses, respectively. Conclusion: IRs of some HOIs in our study were comparable with those in the literature while IRs of other HOIs were not due to differences in study design, post-vaccination risk periods assessed, and vaccine types. Future studies should consider medical chart review for validating HOIs obtained in the EHR.     

Seroprevalence of chronic hepatitis B virus infection and immunity to measles,rubella, tetanus and diphtheria among schoolchildren aged 6–7 years old in the Solomon Islands, 2016

The Western Pacific Region (WPR) established a goal to decrease chronic hepatitis B virus (HBV) infection among children to <1% and to achieve ≥95% hepatitis B vaccine birth dose (HepB-BD) and ≥95% three-dose (HepB3) coverage by 2017. In 2016, we conducted a national serosurvey in the Solomon Islands among 6–7-year-old school children to assess progress towards the control goal and immunity to measles, rubella, tetanus and diphtheria. Eighty schools were selected systematically proportional to their 6–7-year-old population; all 6–7-year-olds were enrolled. We collected basic demographic information and vaccination history. Children were tested for HBV surface antigen (HBsAg) using a rapid test, and for immunity to measles, rubella, tetanus, and diphtheria using a multiplex bead assay. In total, 1,249 out of 1,492 children (84%) were enrolled, among whom 1,169 (94%) underwent HBsAg testing and 1,156 (93%) provided dried blood spots. Almost 80% (n = 982) of enrolled children had vaccination cards, among whom 59% (n = 584) received a timely HepB-BD (within 24 hours of birth), 95% (n = 932) received HepB3, and >90% received vaccines for diphtheria, tetanus, and measles (rubella vaccine was not available at the time). HBsAg prevalence was 3.1% (95% confidence interval (CI): 2.0%–4.9%), with 55% of identified cases from one province. Among 982 children with vaccination cards, HBsAg prevalence was higher among children who had not received a timely HepB-BD and at least two HepB doses compared to those who had (4% vs. 2%). Of 1,156 tested children, immunoprotection estimates were 99% (95% CI: 98%–99%) for measles, 99% (95% CI: 97%–100%) for rubella, 85% (95% CI: 83%–87%) for tetanus, and 51% (95% CI: 47%–55%) for diphtheria. Improving timely HepB-BD coverage and maintaining high HepB3 coverage could help Solomon Islands reach the regional HBV control goal. Low immunity to tetanus and diphtheria suggests the need to introduce booster doses to ensure long-term protection.