Analyzing Subnational Immunization Coverage to Catch up and Reach the Unreached in Seven High-Priority Countries in the Eastern Mediterranean Region, 2019-2021

Yearly national immunization coverage reporting does not measure performance at the subnational level throughout the year and conceals inequalities within countries. We analyzed subnational immunization coverage from seven high-priority countries in our region. We analyzed subnational, monthly immunization data from seven high-priority countries. Five were Gavi eligible (i.e., Afghanistan, Pakistan, Somalia, Syria, and Yemen); these are countries that according to their low income are eligible for support from the Global Alliance on Vaccine and Immunization, while Iraq and Jordan were included because of a recent decrease in immunization coverage and contribution to the regional number of under and unimmunized children. DTP3 coverage, which is considered as the main indicator for the routine immunization coverage as the essential component of the immunization program performance, varied monthly in 2019-2021 before reaching pre-pandemic coverage in the last two months of 2021. Somalia and Yemen had a net gain in DTP3 coverage at the end of 2021, as improvement in 2021 exceeded the regression in 2020. In Pakistan and Iraq, DTP3 improvement in 2021 equaled the 2020 regression. In Afghanistan, Syria and Jordan, the regression in DTP3 coverage continued in 2020 and 2021. The number of districts with at least 6000 zero-dose children improved moderately in Afghanistan and substantially in Somalia throughout the follow-up period. In Pakistan, the geographical distribution differed between 2020 and 2021.Of the three countries with the highest number of zero-dose children, DTP1 coverage reached 109% in Q4 of 2020 after a sharp drop to 69% in Q2 of 2020. However, in Pakistan, the number of zero-dose children decreased to 1/10 of its burden in Q4 of 2021. In Afghanistan, the number of zero-dose children more than a doubled. Among the even countries, adaptation of immunization service to the pandemic varied, depending on the agility of the health system and the performance of the components of the expanded program on immunization. We recommended monitoring administrative monthly immunization coverage data at the subnational level to detect low-performing districts, plan catchup, identify bottlenecks towards reaching unvaccinated children and customize strategies to improve the coverage in districts with zero-dose children throughout the year and monitor progress.

Rotavirus genotypes in children under five years hospitalized with diarrhea in low and middle-income countries: Results from the WHO-coordinated Global Rotavirus Surveillance Network

Rotavirus is the most common pathogen causing pediatric diarrhea and an important cause of morbidity and mortality in low- and middle-income countries. Previous evidence suggests that the introduction of rotavirus vaccines in national immunization schedules resulted in dramatic declines in disease burden but may also be changing the rotavirus genetic landscape and driving the emergence of new genotypes. We report genotype data of more than 16,000 rotavirus isolates from 40 countries participating in the Global Rotavirus Surveillance Network. Data from a convenience sample of children under five years of age hospitalized with acute watery diarrhea who tested positive for rotavirus were included. Country results were weighted by their estimated rotavirus disease burden to estimate regional genotype distributions. Globally, the most frequent genotypes identified after weighting were G1P[8] (31%), G1P[6] (8%) and G3P[8] (8%). Genotypes varied across WHO Regions and between countries that had and had not introduced rotavirus vaccine. G1P[8] was less frequent among African (36 vs 20%) and European (33 vs 8%) countries that had introduced rotavirus vaccines as compared to countries that had not introduced. Our results describe differences in the distribution of the most common rotavirus genotypes in children with diarrhea in low- and middle-income countries. G1P[8] was less frequent in countries that had introduced the rotavirus vaccine while different strains are emerging or re-emerging in different regions.

Capacity-building for conducting COVID-19 vaccine effectiveness studies to enhance evidence-informed vaccination policymaking in the Eastern Mediterranean Region

BACKGROUND

Vaccine effectiveness studies provide evidence on the effects of vaccines for preventing disease and the adverse outcomes following a vaccination rollout programme in a country or a specific population.

AIMS

To document the technical and capacity-building support provided by WHO to countries in the Eastern Mediterranean Region to conduct COVID-19 vaccine effectiveness studies.

METHODS

WHO implemented interventions to enhance the capacity of EMR countries to conduct COVID-19 vaccine effectiveness and similar epidemiological studies. The intervention consisted of several components, including methodological and technical support as well as data and project management at national and regional levels. Two WHO generic protocols were adopted: cohort study among healthcare workers and test-negative design in severe acute respiratory infections surveillance sites.

RESULTS

Egypt, Islamic Republic of Iran, Jordan, and Pakistan participated in the programme. The research protocols were adjusted to country context and settings. WHO provided technical, financial and infrastructure support, including the establishment of quality assessment approaches, study conduct, data management, report development, statistical data analysis, and experience-sharing between the countries. Technical capacity-building was also offered to other countries not involved in the vaccine effectiveness studies.

CONCLUSION

COVID-19 pandemic provided an opportunity to enhance the research capacities of EMR countries for the conduct of vaccine effectiveness studies. The WHO consolidated efforts and its collaboration with countries resulted in enhancement of capacity and research infrastructure, especially in the 4 countries that were supported by this programme. The capacities acquired through the programme would be very useful for other vaccine-preventable communicable diseases, thus better informing national immunization programmes and policies in EMR countries.

Risk Factors for Mortality Among Children Younger Than Age 5 Years With Severe Diarrhea in Low- and Middle-income Countries: Findings From the World Health Organization-coordinated Global Rotavirus and Pediatric Diarrhea Surveillance Networks

BACKGROUND

Diarrhea is the second leading cause of death in children younger than 5 years of age globally. The burden of diarrheal mortality is concentrated in low-resource settings. Little is known about the risk factors for childhood death from diarrheal disease in low- and middle-income countries.

METHODS

Data from the World Health Organization (WHO)-coordinated Global Rotavirus and Pediatric Diarrhea Surveillance Networks, which are composed of active, sentinel, hospital-based surveillance sites, were analyzed to assess mortality in children <5 years of age who were hospitalized with diarrhea between 2008 and 2018. Case fatality risks were calculated, and multivariable logistic regression was performed to identify risk factors for mortality.

RESULTS

This analysis comprises 234 781 cases, including 1219 deaths, across 57 countries. The overall case fatality risk was found to be 0.5%. Risk factors for death in the multivariable analysis included younger age (for <6 months compared with older ages, odds ratio [OR] = 3.54; 95% confidence interval [CI], 2.81-4.50), female sex (OR = 1.18; 95% CI, 1.06-1.81), presenting with persistent diarrhea (OR = 1.91; 95% CI, 1.01-3.25), no vomiting (OR = 1.13; 95% CI, .98-1.30), severe dehydration (OR = 3.79; 95% CI, 3.01-4.83), and being negative for rotavirus on an enzyme-linked immunosorbent assay test (OR = 2.29; 95% CI, 1.92-2.74). Cases from the African Region had the highest odds of death compared with other WHO regions (OR = 130.62 comparing the African Region with the European Region; 95% CI, 55.72-422.73), whereas cases from the European Region had the lowest odds of death.

CONCLUSIONS

Our findings support known risk factors for childhood diarrheal mortality and highlight the need for interventions to address dehydration and rotavirus-negative diarrheal infections.

Inequities in the deployment of COVID-19 vaccine in the WHO Eastern Mediterranean Region, 2020-2021

The WHO Eastern Mediterranean Region (EMR) is characterised by a large range in routine immunisation coverage. We reviewed progress in access, deployment efforts, and use of COVID-19 vaccines in the EMR to identify bottlenecks and propose recommendations. We compiled and analysed data reported to WHO regarding the number of vaccines provided emergency use authorisation (EUA) in each country, the number of vaccine doses allocated and delivered by COVAX, the number of vaccine doses received bilaterally, the date of initiation of vaccination, vaccine usage rate and overall vaccination coverage. In June-July and October-November 2021, we conducted two rounds of a regional survey to assess vaccine acceptance and calculated the weighted proportion of individuals who would get vaccinated once a vaccine is available and recommended. We stratified the analysis according to four groups based on their participation status in COVAX, from the highest to lowest income, that is, (1) fully self-financing high-income countries (group 1), (2) fully self-financing upper middle-income countries (group 2), (3) Advance Market Commitment (AMC) countries not eligible to receive Gavi support (group 3) and (4) AMC countries eligible for Gavi support (group 4). As of 31 December 2021, the median number of vaccines provided with EUA was 6 for group 1, 11 for group 2, 8 for group 3 and 9 for group 4. On the same date, COVAX had delivered 179 793 310 doses to EMR countries. Vaccination started on 10 December 2020 in group 1, on 13 December 2020 in group 2, on 30 December 2020 in group 3 and on 20 January 2021 in group 4. The regional acceptance survey (first round) pointed to higher vaccine acceptance in group 1 (96%), than in others, including group 2 (73.9%), group 3 (78.8%) and group 4 (79.3%), with identical patterns in the second round (98%, 78%, 84% and 76%), respectively. Usage of vaccine allocated by COVAX to participating countries was 89% in group 1, 75% in group 2, 78% in group 3 and 42% in group 4. The full dose and partial dose coverage decreased with the income groups of countries, from 70% and 6% in group 1, to 43% and 8% in group 2, to 33% and 11% in group 3, and 20% and 8% in group 4. All 22 EMR countries introduced COVID-19 vaccines by 21 April 2021, but with major inequities in coverage. Additional efforts are needed to address the determinants of unequal vaccine coverage at all stages of the result chain to improve vaccine equity.

WHO's support for COVID-19 research and knowledge management in the Eastern Mediterranean Region

Health research, innovation and knowledge management remain major priorities of the WHO’s response to the COVID-19 pandemic. WHO’s Eastern Mediterranean Regional Office (EMRO) supports priority research initiatives that address gaps in current knowledge regarding the COVID-19 pandemic. Through a specific call for proposals, 122 research proposals were received and reviewed in 2020, of which 17 were recommended for funding from eight countries. Ten countries in the region participated in the global solidarity trial to assess potential therapies for COVID-19. In addition, WHO advocated for early serological and epidemiological investigations (‘COVID-19 Unity Studies’) on the general population, healthcare workers, pregnant women and neonates, and extending technical, financial and material support for them.

Starting in early 2020, scholarly articles on COVID-19 have been published in every issue of the Eastern Mediterranean Health Journal. More than 6300 publications on COVID-19 were made available on the WHO knowledge management portal in the last year alone. WHO is also supporting countries in conducting studies to assess the field effectiveness of vaccines deployed nationally. To build and strengthen country capacities, regional webinars and intercountry meetings were conducted on research ethics, national health information systems and evidence-based health policy making. With support from WHO EMRO’s new research and knowledge management pillar, countries in the region were well equipped to contribute to a global understanding of the novel virus’s characteristics, as well as employ a national response based on informed evidence.

The Global Landscape of Pediatric Bacterial Meningitis Data Reported to the World Health Organization-Coordinated Invasive Bacterial Vaccine-Preventable Disease Surveillance Network, 2014-2019

BACKGROUND

The World Health Organization (WHO) coordinates the Global Invasive Bacterial Vaccine-Preventable Diseases (IB-VPD) Surveillance Network to support vaccine introduction decisions and use. The network was established to strengthen surveillance and laboratory confirmation of meningitis caused by Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis.

METHODS

Sentinel hospitals report cases of children <5 years of age hospitalized for suspected meningitis. Laboratories report confirmatory testing results and strain characterization tested by polymerase chain reaction. In 2019, the network included 123 laboratories that follow validated, standardized testing and reporting strategies.

RESULTS

From 2014 through 2019, >137 000 suspected meningitis cases were reported by 58 participating countries, with 44.6% (n = 61 386) reported from countries in the WHO African Region. More than half (56.6%, n = 77 873) were among children <1 year of age, and 4.0% (n = 4010) died among those with reported disease outcome. Among suspected meningitis cases, 8.6% (n = 11 798) were classified as probable bacterial meningitis. One of 3 bacterial pathogens was identified in 30.3% (n = 3576) of these cases, namely S. pneumoniae (n = 2177 [60.9%]), H. influenzae (n = 633 [17.7%]), and N. meningitidis (n = 766 [21.4%]). Among confirmed bacterial meningitis cases with outcome reported, 11.0% died; case fatality ratio varied by pathogen (S. pneumoniae, 12.2%; H. influenzae, 6.1%; N. meningitidis, 11.0%). Among the 277 children who died with confirmed bacterial meningitis, 189 (68.2%) had confirmed S. pneumoniae. The proportion of pneumococcal cases with pneumococcal conjugate vaccine (PCV) serotypes decreased as the number of countries implementing PCV increased, from 77.8% (n = 273) to 47.5% (n = 248). Of 397 H. influenzae specimens serotyped, 49.1% (n = 195) were type b. Predominant N. meningitidis serogroups varied by region.

CONCLUSIONS

This multitier, global surveillance network has supported countries in detecting and serotyping the 3 principal invasive bacterial pathogens that cause pediatric meningitis. Streptococcus pneumoniae was the most common bacterial pathogen detected globally despite the growing number of countries that have nationally introduced PCV. The large proportions of deaths due to S. pneumoniae reflect the high proportion of meningitis cases caused by this pathogen. This global network demonstrated a strong correlation between PCV introduction status and reduction in the proportion of pneumococcal meningitis infections caused by vaccine serotypes. Maintaining case-based, active surveillance with laboratory confirmation for prioritized vaccine-preventable diseases remains a critical component of the global agenda in public health.The World Health Organization (WHO)-coordinated Invasive Bacterial Vaccine-Preventable Disease (IB-VPD) Surveillance Network reported data from 2014 to 2019, contributing to the estimates of the disease burden and serotypes of pediatric meningitis caused by Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis.

Evaluation of post-introduction COVID-19 vaccine effectiveness: Summary of interim guidance of the World Health Organization

Phase 3 randomized-controlled trials have provided promising results of COVID-19 vaccine efficacy, ranging from 50 to 95% against symptomatic disease as the primary endpoints, resulting in emergency use authorization/listing for several vaccines. However, given the short duration of follow-up during the clinical trials, strict eligibility criteria, emerging variants of concern, and the changing epidemiology of the pandemic, many questions still remain unanswered regarding vaccine performance. Post-introduction vaccine effectiveness evaluations can help us to understand the vaccine's effect on reducing infection and disease when used in real-world conditions. They can also address important questions that were either not studied or were incompletely studied in the trials and that will inform evolving vaccine policy, including assessment of the duration of effectiveness; effectiveness in key subpopulations, such as the very old or immunocompromised; against severe disease and death due to COVID-19; against emerging SARS-CoV-2 variants of concern; and with different vaccination schedules, such as number of doses and varying dosing intervals. WHO convened an expert panel to develop interim best practice guidance for COVID-19 vaccine effectiveness evaluations. We present a summary of the interim guidance, including discussion of different study designs, priority outcomes to evaluate, potential biases, existing surveillance platforms that can be used, and recommendations for reporting results.

Out Come of Wide Local Excision with and without Corticosteroid Therapy in Management of Idiopathic Granulomatous Mastitis

Introduction:

Idiopathic granulomatous mastitis is a rare benign breast disease. Initial reports from hospitals in Egypt from Departments of Pathology at Cancer Institutes of Cairo, Tanta and Mansoura Universities; indicate that the disease is not as rare as that in the developed countries. It often mimics breast carcinoma both clinically and radiologically. Histological examination is the gold standard for diagnosis. Management of Idiopathic granulomatous mastitis is still debatable. In our study, we aimed to evaluate the addition of corticosteroid therapy to surgical excision in management of idiopathic granulomatous mastitis.

Patients and Methods:

This is a comparative study was conducted at Ain-Shams University Hospital’s breast clinic on patients with idiopathic granulomatous mastitis from to August 2015 till September 2018. Thirty patients were divided into 2 groups. Group (A) includes patients who underwent surgical management only. Group (B) includes patients who received corticosteroid therapy according to the severity of the cases then surgical Excision was done for the residual lesion. Follow up of all cases up to 1-2 years was done to document the recurrence rate and compare the cosmetic outcome of both groups. Informed consent was obtained from all patients included in the study.

Results:

The mean age of the affected women was 38.80 and 33.13 in group (A) and group (B), respectively and it wasn’t statistically different (p value = 0.099). The most common presenting symptom was a palpable mass in the breast (66.7% and 93.3%) in group (A) and group (B) respectively. Recurrence rate was higher in group (A) (40%) with no recurrence documented in group (B) however 2 cases were omitted from the study due to steroid noncompliance and complications. Cosmetic outcome was excellent in 76.9% of group (B) and good in 53.3% of group (A).

Conclusion:

Systemic steroid therapy with surgical resection is the recommended as first-line treatment strategy for IGM as it shows less recurrence rate and surgical scarring. Increased awareness of IGM will increase their understanding and improve their management.

Global impact of rotavirus vaccine introduction on rotavirus hospitalisations among children under 5 years of age, 2008-16: findings from the Global Rotavirus Surveillance Network

Summary

Background

Rotavirus vaccine use in national immunisation programmes has led to declines in hospital admissions for rotavirus gastroenteritis among children; however, the global impact of rotavirus vaccine introduction has not been described using primary data. We describe the impact of rotavirus vaccine introduction on admissions for acute rotavirus gastroenteritis in primarily low-income and middle-income countries, using 9 years of data from the WHO-coordinated Global Rotavirus Surveillance Network (GRSN).

Methods

Between Jan 1, 2008, and Dec 31, 2016, children younger than 5 years of age who were admitted to hospital with acute gastroenteritis were prospectively enrolled in GRSN sites. We included sites that enrolled children and collected stool specimens monthly and tested at least 100 specimens annually in the impact analysis, with a separate analysis taking into account site continuity. We compared proportions of acute gastroenteritis cases positive for rotavirus in the pre-vaccine and post-vaccine periods and calculated mean proportion changes for WHO regions, with 95% CIs; these findings were then compared with interrupted time series analyses. We did further sensitivity analyses to account for rotavirus vaccination coverage levels and sites that collected specimens for at least 11 months per year and tested at least 80 specimens per year. We also analysed the age distribution of rotavirus-positive cases before and after vaccine introduction.

Findings

403 140 children younger than 5 years of age admitted to hospital with acute gastroenteritis from 349 sites in 82 countries were enrolled over the study period, of whom 132 736 (32.9%) were positive for rotavirus. We included 305 789 children from 198 sites in 69 countries in the impact analysis. In countries that had not introduced rotavirus vaccine in their national immunisation programmes, rotavirus was detected in 38.0% (95% CI 4.8–73.4) of admissions for acute gastroenteritis annually whereas in those that have introduced the vaccine, rotavirus was detected in 23.0% (0.7–57.7) of admissions for acute gastroenteritis, showing a 39.6% (35.4–43.8) relative decline following introduction. Interrupted time series analyses confirmed these findings. Reductions by WHO regions ranged from 26.4% (15.0–37.8) in the Eastern Mediterranean Region to 55.2% (43.0–67.4) in the European Region and were sustained in nine countries (contributing up to 31 sites) for 6–10 years. The age distribution of children with rotavirus gastroenteritis shifted towards older children after rotavirus vaccine introduction.

Interpretation

A significant and sustained reduction in the proportion of hospital admissions for acute gastroenteritis due to rotavirus was seen among children younger than 5 years in GRSN sites following rotavirus vaccine introduction. These findings highlight the need to incorporate rotavirus vaccines into immunisation programmes in countries that have not yet introduced them and underline the importance of high-quality surveillance.

Anterior Intercostal Artery Perforator Flap as a Simple Technique for Partial Breast Reconstruction: Our Institutional Initial Experience

Background:

The oncoplastic surgery has brought new dimensions to breast conserving surgery and added the aesthetic principles of breast surgery to breast cancer management. Recently there's a lot of volume replacement techniques without significant donor site morbidity .The anterior intercostal artery perforator (AICAP) flap is a suitable option in partial breast reconstruction for lower pole tumors in small and medium sized breasts.

Objectives:

The aim of this study is to report our clinical experience with anterior intercostal perforator flap in partial breast reconstruction

Methodology:

25 cases were performed between April 2018 to June 2019 at in Ain shams university hospitals for selected patients with lower breast pole tumors with small and medium sized breast and other option like reduction mMDTmoplasty wasn't favorable for them.

Results:

A total of 25 patient were selected by the multidisplinary team at Ain shams university hospital for partial breast reconstruction with anterior intercostal artery perforator flap . The mean age of the cases was 45.68 with mean body mass index of 32.32. The mean operative time for the flap was 64 minutes while the hospital stay was ranging from 1-2 days .Follow-up for local recurrence was from 6 to 14 months. There was 1 case with wound complication (4%). The cosmetic outcome was assessed by the MDT and a giving score from 1-5 was used with 1 is the least favorable cosmetic outcome and 5 is the best result 76% of the cases scored 5, 14% scored 4, 8% scored 3. According to patient satisfaction a score from 1 to 5 was used with the score 1 is least satisfied and score 5 represents the most satisfaction level, there was 80% of the patient gave the score 5, 12% of the cases gave the score 4 and 8% of the cases gave the score 3

Conclusions:

Based on our experience, partial breast reconstruction using AICAP flap is a reliable option for lower breast tumors in small-to-moderate breast size with perfect cosmetic outcome and negligible rate of complication.

Home-based records' quality and validity of caregivers' recall of children's vaccination in Lebanon

INTRODUCTION

Home-based records (HBRs) (also known as vaccination cards) and caregivers' recall are the main means to ascertain vaccination status; however, data on the quality of HBRs and the validity of recall vaccination data compared to HBRs is scarce. This manuscript presents results from two analyses related to HBRs, one on HBR pictures taken during a vaccination coverage survey, including an assessment of the HBR quality and legibility, and an evaluation of the agreement between caregivers' recall and the vaccination information in the HBRs.

METHODS

Using pictures from 500 randomly selected HBRs collected during the 2016 district-based immunization coverage evaluation survey in Lebanon, two independent researchers assessed the quality of the picture and then of the HBR itself against a pre-defined set of criteria. HBRs were classified into three types: private, public and all others. In addition, caregivers' recall was compared to data found in vaccination HBRs to assess measures of vaccination status agreement for 5713 children for whom both sources of data were available.

RESULTS

Over 90% of the 500 HBR pictures reviewed were considered adequate to assess the HBR quality. In the sample, most cards were type 1 (41%), followed by type 2 (34%). Most HBRs met the set criteria for quality in terms of physical condition and legibility, while, among the 28 different types of cards, vaccination cards' content and design met a moderate level of quality. Concordance, sensitivity, specificity, positive and negative predictive values, and the Kappa statistic showed diverse levels of agreement for vaccination status per vaccine dose between caregivers' recall and vaccination HBRs.

CONCLUSION

This study illustrates that taking pictures of HBRs in a coverage survey is feasible and useful to conduct secondary analyses related to HBRs, such as assessing their quality and comparing recall with HBRs when both sources of data are available.

Vaccination coverage in Lebanon following the Syrian crisis: results from the district-based immunization coverage evaluation survey 2016

BACKGROUND

Following the Syrian crisis, a substantial influx of Syrian refugees into Lebanon posed new challenges to optimal vaccination coverage for all children residing in the country. In 2016, the district-based immunization coverage evaluation survey (CES) assessed routine immunization coverage at the district level in Lebanon among children aged 12-59 months.

METHODS

A cross-sectional multistage cluster survey was conducted in all of Lebanon (with the exception of the Nabatieh district) using the World Health Organization (WHO) recommended Expanded Programme on Immunization (EPI) methodology adapted to the local context. A survey questionnaire consisting of closed and open-ended questions concerning demographic information and the child's immunization status was administered to collect immunization status information.

RESULTS

Among surveyed children aged 12-59 months, irrespective of nationality, vaccination coverage at the national level for any recommended last dose was below the targeted 95%. Generally, vaccination coverage levels increased with age and were higher among Lebanese than Syrian children. However, large variations were revealed when coverage rates were analyzed at the district level. Vaccination was significantly associated with nationality, age, mother's educational status and the place of vaccination. Common reasons for undervaccination included the child's illness at the time of vaccine administration, vaccination fees, lack of awareness or a doctor's advice not to vaccinate during campaigns.

CONCLUSIONS

Substantial variability exists in vaccination coverage among children aged 12-59 months residing in different districts in Lebanon. Immunization coverage reached 90% or above only for the first doses of polio and pentavalent vaccines. A considerable dropout rate from the first dose of any vaccine is observed. Efforts to optimize coverage levels should include increased vaccination initiatives targeting both refugee children and children from vulnerable host communities, increased cooperation between public and private vaccine providers, improved training for vaccine providers to adhere to complete vaccine administration recommendations, and increased awareness among caregivers.

Factors affecting age-appropriate timeliness of vaccination coverage among children in Lebanon

Background: The effect of immunization does not only depend on its completeness, but also on its timely administration. Routine childhood vaccinations schedules recommend that children receive the vaccine doses at specific ages. This article attempts to assess timeliness of routine vaccination coverage among a sub-sample of children from a survey conducted in 2016. Methods: This analysis was based on data from a cross-sectional multistage cluster survey conducted between December 2015 and June 2016 among caregivers of children aged 12-59 months in all of Lebanon using a structured survey questionnaire. The analysis used Kaplan-Meier curves and logistic regression to identify the predictors of age-appropriate immunization. Results: Among the 493 randomly selected children, timely administration of the third dose of polio vaccine, diphtheria-tetanus-pertussis (DTP)-containing vaccine and hepatitis B (HepB) vaccine occurred in about one-quarter of children. About two-thirds of children received the second dose of a measles-containing vaccine (MCV) within the age interval recommended by the Expanded Programme on Immunization (EPI). Several factors including socio-demographic, knowledge, beliefs and practices were found to be associated with age-appropriate vaccination; however, this association differed between the types and doses of vaccine. Important factors associated with timely vaccination included being Lebanese as opposed to Syrian and being born in a hospital for hepatitis B birth dose; believing that vaccination status was up-to-date was related to untimely vaccination. Conclusions: The results suggest that there is reason for concern over the timeliness of vaccination in Lebanon. Special efforts need to be directed towards the inclusion of timeliness of vaccination as another indicator of the performance of the EPI in Lebanon.

Introduction of Inactivated Polio Vaccine, Withdrawal of Type 2 Oral Polio Vaccine, and Routine Immunization Strengthening in the Eastern Mediterranean Region

The Global Polio Eradication Initiative has reduced the global incidence of polio by 99% and the number of countries with endemic polio from 125 to 3 countries. The Polio Eradication and Endgame Strategic Plan 2013–2018 (Endgame Plan) was developed to end polio disease. Key elements of the endgame plan include strengthening immunization systems using polio assets, introducing inactivated polio vaccine (IPV), and replacing trivalent oral polio vaccine with bivalent oral polio vaccine (“the switch”). Although coverage in the Eastern Mediterranean Region (EMR) with the third dose of a vaccine containing diphtheria, tetanus, and pertussis antigens (DTP3) was ≥90% in 14 countries in 2015, DTP3 coverage in EMR dropped from 86% in 2010 to 80% in 2015 due to civil disorder in multiple countries. To strengthen their immunization systems, Pakistan, Afghanistan, and Somalia developed draft plans to integrate Polio Eradication Initiative assets, staff, structure, and activities with their Expanded Programmes on Immunization, particularly in high-risk districts and regions. Between 2014 and 2016, 11 EMR countries introduced IPV in their routine immunization program, including all of the countries at highest risk for polio transmission (Afghanistan, Pakistan, Somalia, and Yemen). As a result, by the end of 2016 all EMR countries were using IPV except Egypt, where introduction of IPV was delayed by a global shortage. The switch was successfully implemented in EMR due to the motivation, engagement, and cooperation of immunization staff and decision makers across all national levels. Moreover, the switch succeeded because of the ability of even the immunization systems operating under hardship conditions of conflict to absorb the switch activities.

Experiences and Lessons From Polio Eradication Applied to Immunization in 10 Focus Countries of the Polio Endgame Strategic Plan

Nine polio areas of expertise were applied to broader immunization and mother, newborn and child health goals in ten focus countries of the Polio Eradication Endgame Strategic Plan: policy & strategy development, planning, management and oversight (accountability framework), implementation & service delivery, monitoring, communications & community engagement, disease surveillance & data analysis, technical quality & capacity building, and partnerships. Although coverage improvements depend on multiple factors and increased coverage cannot be attributed to the use of polio assets alone, 6 out of the 10 focus countries improved coverage in three doses of diphtheria tetanus pertussis containing vaccine between 2013 and 2015. Government leadership, evidence-based programming, country-driven comprehensive operational annual plans, community partnership and strong accountability systems are critical for all programs and polio eradication has illustrated these can be leveraged to increase immunization coverage and equity and enhance global health security in the focus countries.

Understanding the different physical examination tests for suspected meniscal tears

Meniscal tears are common in sport medicine practice. Many articles and textbooks discuss the relative validity of the different components of the physical examination with respect to their sensitivity, specificity, and positive/negative predictive values as if they were diagnostic tests. In this article, we demonstrate why this approach is limited, including the heterogeneous nature of meniscal tear pathology (e.g., posterior vs anterior). Therefore, in this article, we categorize all the published tests in the literature with regards to the mechanism underlying a positive test. We believe our approach provides the clinician with additional tools to diagnose tears. Future research should explore predictive models based on the different components accounting for heterogeneous pathology and different patient contexts.

Structural investigation of bacteriorhodopsin and some of its photoproducts by polarized Fourier transform infrared spectroscopic methods-difference spectroscopy and photoselection

The direction of selected IR-transition moments of the retinal chromophore of bacteriorhodopsin (BR) and functional active amino acid residues are determined for light- and dark-adapted BR and for the intermediates K and L of the photocycle. Torsions around single bonds of the chromophore are found to be present in all the investigated BR states. The number of twisted single bonds and the magnitude of these torsions decreases in the order K, L, light-adapted BR, dark-adapted BR. In the last, only the C(14)-C(15) single bond is twisted. The orientation of molecular planes and chemical bonds of such protein side chains, which are perturbed during the transition of light-adapted BR to the respective intermediates, are deduced and the results compared with the current three dimensional model of BR. Trp 86 and Trp 185 are found to form a rigid part of the protein, whereas Asp 96 and Asp 115 perform molecular rearrangements upon formation of the L-intermediate.

Metal binding by bacteria from uranium mining waste piles and its technological applications

Uranium mining waste piles, heavily polluted with radionuclides and other toxic metals, are a reservoir for bacteria that have evolved special strategies to survive in these extreme environments. Understanding the mechanisms of bacterial adaptation may enable the development of novel bioremediation strategies and other technological applications. Cell isolates of Bacillus sphaericus JG-A12 from a uranium mining waste pile in Germany are able to accumulate high amounts of toxic metals such as U, Cu, Pb, Al, and Cd as well as precious metals. Some of these metals, i.e. U, Cu, Pd(II), Pt(II) and Au(III), are also bound by the highly orderd paracrystalline proteinaceous surface layer (S-layer) that envelopes the cells of this strain. These special capabilities of the cells and the S-layer proteins of B. sphaericus JG-A12 are highly interesting for the clean-up of uranium contaminated waste waters, for the recovery of precious metals from electronic wastes, and for the production of metal nanoclusters. The fabricated nanoparticles are promising for the development of novel catalysts. This work reviews the molecular biology of the S-layer of the strain JG-A12 and the S-layer dependent interactions of the bacterial cells with metals. It presents future perspectives for their application in bioremediation and nanotechnology.

Properties and Planned Use of the Intense THz Radiation from ELBE at Dresden-Rossendorf

The radiation source ELBE atDresden-Rossendorf is centered around asuperconducting ELectron accelerator ofhigh Brilliance and low Emittance (ELBE) which produces electronbeams up to 40 MeV. This new facility delivers secondary radiation of differentkinds. Special emphasis will be given tothe production of intense THz radiationfrom its Free-Electron Lasers (FEL). This radiation will be usedfor various research activities including the life sciences. Two additionalfemtosecond Ti:sapphire laser systems allowto exploit different methods of THzgeneration for such investigations.

Transducin-dependent protonation of glutamic acid 134 in rhodopsin

A highly conserved carboxylic acid residue in rhodopsin, Glu(134), modulates transducin (G(t)) interaction. It has been postulated that Glu(134) becomes protonated upon receptor activation. We studied the interaction between rhodopsin and G(t) using Fourier transform infrared (FTIR) difference spectroscopy combined with attenuated total reflection (ATR). Formation of the complex between G(t) and photoactivated rhodopsin reconstituted into phosphatidylcholine vesicles caused prominent infrared absorption increases at 1641, 1550, and 1517 cm(-)(1). The rhodopsin mutant E134Q was also studied. When measured in the presence of G(t), replacement of Glu(134) by glutamine abolished the low-frequency part of a broad absorption band at 1735 cm(-)(1) that is normally superimposed on the light-induced absorption changes of Asp(83) and Glu(122) of rhodopsin. In addition, a negative absorption band at 1400 cm(-)(1) that is evoked by interaction of native metarhodopsin II (MII) with G(t) was not observed in the difference spectrum of the E134Q mutant. Thus, Glu(134) is ionized in the dark and exhibits a symmetrical COO(-) stretching vibration at 1400 cm(-)(1). Glu(134) becomes protonated in the G(t)-MII complex and displays a C=O stretching mode near 1730 cm(-)(1). The E134Q mutation also affects absorption changes attributable to lipids, suggesting that the protonation of Glu(134) is linked to transfer of the carboxylic acid side chain from a polar to a nonpolar environment by becoming exposed to the lipid phase when G(t) binds. These results show directly that Glu(134) becomes protonated in MII upon G(t) binding and suggest that changes in receptor conformation affect lipid-protein interactions.