Factors affecting the introduction of new vaccines to poor nations: a comparative study of the Haemophilus influenzae type B and hepatitis B vaccines. PLoS One. 2010;5:e13802. [PMID: 21072192 DOI: 10.1371/journal.pone.0013802]

Resistance to Change

Advances in medical technology do not follow a smooth process and are highly variable. Implementation can occasionally be rapid, but often faces varying degrees of resistance resulting at the very least in delayed implementation. Using qualitative comparative analysis, we have evaluated numerous technological advances from the perspective of how they were introduced, implemented, and opposed. Resistance varies from benign - often happening because of inertia or lack of resources to more active forms, including outright opposition using both appropriate and inappropriate methods to resist/delay changes in care. Today, even public health has become politicized, having nothing to do with the underlying science, but having catastrophic results. Two other corroding influences are marketing pressure from the private sector and vested interests in favor of one outcome or another. This also applies to governmental agencies. There are a number of ways in which papers have been buried including putting the thumb on the scale where reviewers can sabotage new ideas. Unless we learn to harness new technologies earlier in their life course and understand how to maneuver around the pillars of obstruction to their implementation, we will not be able to provide medical care at the forefront of technological capabilities.

Effect of vaccination patterns and vaccination rates on the spread and mortality of the COVID-19 pandemic

Objectives

Acquiring herd immunity through vaccination is the best way to curb the COVID-19 infection. Many countries have attempted to reach the herd immunity threshold as early as possible since the commencement of vaccination at the end of 2020. The purpose of this study is to (1) examine whether the pattern of vaccination rates affects the spread of COVID-19 and the consequent mortality and (2) investigate the level of cumulative vaccination rates that can begin to have an impact on reducing the spread and mortality of the pandemic.

Methods

This study selected 33 countries with higher vaccination rates as its sample set, classifying them into three groups as per vaccination patterns.

Results

The results showed that vaccination patterns have a significant impact on reducing spread and mortality. The full-speed vaccination pattern showed greater improvement in the spread of the COVID-19 pandemic than the other two patterns, while the striving vaccination pattern improved the most in terms of mortality. Secondly, the spread and mortality of the COVID pandemic started to significantly decline when the average cumulative vaccination rate reached 29.06 doses per 100 people and 7.88 doses per 100 people, respectively.

Conclusion

The study highlights the important role of vaccination patterns and the VTMR in reducing the epidemic spread and mortality.

Global analysis of timely COVID-19 vaccinations: improving governance to reinforce response policies for pandemic crises

Purpose

The goal of this study is to analyze the relationship between public governance and COVID-19 vaccinations during early 2021 to assess the preparedness of countries to timely policy responses to cope with pandemic crises.

Design/methodology/approach

This global study elaborates descriptive statistics, correlations, regression analyses and Independent Samples T-Test on 112 countries, comparing those with high/low level of governance, to determine whether statistical evidence supports the hypothesis that good governance can improve the timely administration of vaccines.

Findings

Bivariate correlation reveals that doses of vaccines administered × 100 inhabitants have a high positive association with the General Index of Governance (r = 0.58, p-value <0.01). The result is confirmed by partial correlation (controlling density of population per km2): r = 0.584, p-value <0.001. The coefficient of regression in the models also indicates that an increase in the General Index of Governance improves the expected administration of doses of COVID-19 vaccines (p-value <0.001).

Research limitations/implications

Although this study has provided interesting results that are, of course, tentative, it has several limitations. First, a limitation is the lack of data in several countries. Second, not all the possible confounding factors that affect the vaccination against COVID-19 are investigated, such as country-specific health investments and expenditures, and these aspects should be examined in the future development of this research. A third limit is related to the measurement of governance through the World Governance Indicators, which are based only on perceptions and can be biased by different socio-economic factors.

Practical implications

The identification of factors determining the timely vaccinations may help to design best practices of health policy for improving the resilience of countries to face pandemic crises.

Social implications

The improvement of preparedness of countries through good governance can foster a rapid rollout of vaccinations to cope with pandemic threats and the negative effects of their socio-economic impact.

Originality/value

This study presents a global analysis of the role of public governance for timely vaccinations to face pandemic crises in society.

Preparedness of countries to face COVID-19 pandemic crisis: Strategic positioning and factors supporting effective strategies of prevention of pandemic threats

The Coronavirus Disease 2019 (COVID-19) continues to generate a constant pandemic threat with new mutations of the viral agent (SARS-CoV-2) that create socioeconomic issues. One of the fundamental problems is the evaluation of the preparedness of countries to cope with COVID-19 pandemic crisis to detect and support factors associated with the reduction of mortality and the growth of vaccinations in society. The study here confronts this problem by developing two basic indexes, which measure the performance of countries to face pandemic threats. In particular, the Index r (as resilience) detects the countries having the best performance in the reduction of the negative impact of mortality related to COVID-19 pandemic and the Index p (as preparedness and prevention) assesses best-performer countries to support COVID-19 vaccinations in order to constrain future pandemic threats and support the recovery of socioeconomic systems. Index of resilience is a composite measure based on three indicators associated with COVID-19, given by average mortality, hospital occupancy and Intensive Care Units occupancy per 100 000 people, producing an overall score; Index of preparedness/prevention is a composite measure of two indicators related to COVID-19 vaccinations (i.e., doses of vaccines administered and total vaccinates per 100 000 people), producing also an overall score of performance. The application of these indexes on a case study of European countries, having a homogenous socioeconomic area, shows the strategic positioning of countries to cope with a major pandemic threat. Findings reveal that all countries have some weaknesses and no country has a high preparedness to cope with a major epidemic or pandemic. Moreover, results suggest that best-performer countries to cope with COVID-19 pandemic crisis have a smaller size of population and/or better public governance, associated with high expenditures in health system. These indexes can help policymakers for designing effective strategies to improve preparedness and prevention of countries to face future pandemic threats.

The use of Qualitative Comparative Analysis (QCA) to address causality in complex systems: a systematic review of research on public health interventions

Background

Qualitative Comparative Analysis (QCA) is a method for identifying the configurations of conditions that lead to specific outcomes. Given its potential for providing evidence of causality in complex systems, QCA is increasingly used in evaluative research to examine the uptake or impacts of public health interventions. We map this emerging field, assessing the strengths and weaknesses of QCA approaches identified in published studies, and identify implications for future research and reporting.

Methods

PubMed, Scopus and Web of Science were systematically searched for peer-reviewed studies published in English up to December 2019 that had used QCA methods to identify the conditions associated with the uptake and/or effectiveness of interventions for public health. Data relating to the interventions studied (settings/level of intervention/populations), methods (type of QCA, case level, source of data, other methods used) and reported strengths and weaknesses of QCA were extracted and synthesised narratively.

Results

The search identified 1384 papers, of which 27 (describing 26 studies) met the inclusion criteria. Interventions evaluated ranged across: nutrition/obesity (n = 8); physical activity (n = 4); health inequalities (n = 3); mental health (n = 2); community engagement (n = 3); chronic condition management (n = 3); vaccine adoption or implementation (n = 2); programme implementation (n = 3); breastfeeding (n = 2), and general population health (n = 1). The majority of studies (n = 24) were of interventions solely or predominantly in high income countries. Key strengths reported were that QCA provides a method for addressing causal complexity; and that it provides a systematic approach for understanding the mechanisms at work in implementation across contexts. Weaknesses reported related to data availability limitations, especially on ineffective interventions. The majority of papers demonstrated good knowledge of cases, and justification of case selection, but other criteria of methodological quality were less comprehensively met.

Conclusion

QCA is a promising approach for addressing the role of context in complex interventions, and for identifying causal configurations of conditions that predict implementation and/or outcomes when there is sufficiently detailed understanding of a series of comparable cases. As the use of QCA in evaluative health research increases, there may be a need to develop advice for public health researchers and journals on minimum criteria for quality and reporting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10926-2.

Air pollution effects on adult mortality rate in developing countries

Although industrialisation is a crucial aspect of economic growth across developing nations, through the release of air contaminants, industrial activities may also create adverse environmental health consequences. Noting that continuous production and other economic activities are crucial for continued survival, this study explores this issue by including the role of governance that is deemed essential but the literature is relatively sparse particularly in the context of developing countries. This research empirically analyses the relationship between air pollution and adult mortality rates from 72 developing countries from the period of 2010 until 2017. Particulate matter (PM_2.5) and carbon dioxide (CO₂) are used as indicators of air pollution. From the generalized method of moments (GMM) estimations, the results reveal that air pollution negatively affects adult mortality rate. The result reveals that a 10% increase in the PM_2.5 level induces the adult mortality rates to increase between 0.04% and 0.06%. In addition, the government significantly moderates the negative effect of air pollution on adult mortality, whereby a one-unit enhancement in governance quality index reduces mortality among the adults in the developing countries by 0.01%. On the other hand, CO₂ emission also appears to be positive, but not statistically significant. The results suggest that governance and public health interplay in the sense of a transition towards economic development for improved living and health states can be achievable with improved governance quality.

Political and Governance Challenges to Achieving Global HIV Goals with Injecting Drug Users: The Case of Pakistan

Background: The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recently set the ambitious "90-90-90 target" of having 90% of people living with HIV (PLHIV) know their status, receive antiretroviral therapy (ART), and achieve viral suppression by 2020. This ambitious new goal is occurring in a context of global "scale-down" following nearly a decade of heightened investment in HIV prevention and treatment efforts. Arguably international goals spur action, however, setting unrealistic goals that do not take weak health systems and variations in the nature of the epidemic across countries into consideration may set them up for failure in unproductive ways that lead to a decline in confidence in global governance institutions. This study explores how policy actors tasked with implementing HIV programs navigate the competing demands placed upon them by development targets and national politics, particularly in the current context of waning international investments towards HIV.

Methods: To examine these questions, we interviewed 29 key informants comprising health experts in donor organizations and government employees in HIV programs in Pakistan, a country where HIV programs must compete with other issues for attention. Themes were identified inductively through an iterative process and findings were triangulated with various data sources and existing literature.

Results: We found both political and governance challenges to achieving the target, particularly in the context of the global HIV scale-down. Political challenges included, low and heterogeneous political commitment for HIV and a conservative legal environment that contributed towards a ban on opiate substitution therapy, creating low treatment coverage. Governance challenges includedstrained state and non-governmental organization (NGO) relations creating a hostile service delivery environment, weak bureaucratic and civil society capacity contributing to poor regulation of the health infrastructure, and resource mismanagement on both the part of the government and NGOs.

Conclusion: Our findings suggest that in a context of waning international attention to HIV, policy actors on the ground face a number of practical hurdles to achieving the ambitious targets set out by international agencies. Greater attention to the political and governance challenges of implementing HIV programs in low- and middle-income countries (LMICs) could help technical assistance agencies to develop more realistic implementation plans.

Health sector governance: should we be investing more?

Governance is central to improving health sector performance and achieving Universal Health Coverage (UHC). However, the growing body of research on governance and health has not yet led to a global consensus on the need for more investment in governance interventions to improve health. This paper aims to summarise the latest evidence on the influence of governance on health, examines how we can assess governance interventions and considers what might constitute good investments in health sector governance in resource constrained settings. The paper concludes that agendas for improving governance need to be realistic and build on promising in-country innovation and the growing evidence base of what works in different settings. For UHC to be achieved, governance will require new partnerships and opportunities for dialogue, between state and non-state actors. Countries will require stronger platforms for effective intersectoral actions and more capacity for applied policy research and evaluation. Improved governance will also come from collective action across countries in research, norms and standards, and communicable disease control.

Navigating the complexities of qualitative comparative analysis: case numbers, necessity relations, and model ambiguities

BACKGROUND

In recent years, the method of Qualitative Comparative Analysis (QCA) has been enjoying increasing levels of popularity in evaluation and directly neighboring fields. Its holistic approach to causal data analysis resonates with researchers whose theories posit complex conjunctions of conditions and events. However, due to QCA's relative immaturity, some of its technicalities and objectives have not yet been well understood.

OBJECTIVES

In this article, I seek to raise awareness of six pitfalls of employing QCA with regard to the following three central aspects: case numbers, necessity relations, and model ambiguities. Most importantly, I argue that case numbers are irrelevant to the methodological choice of QCA or any of its variants, that necessity is not as simple a concept as it has been suggested by many methodologists, and that doubt must be cast on the determinacy of virtually all results presented in past QCA research.

METHOD

By means of empirical examples from published articles, I explain the background of these pitfalls and introduce appropriate procedures, partly with reference to current software, that help avoid them.

CONCLUSION

QCA carries great potential for scholars in evaluation and directly neighboring areas interested in the analysis of complex dependencies in configurational data. If users beware of the pitfalls introduced in this article, and if they avoid mechanistic adherence to doubtful "standards of good practice" at this stage of development, then research with QCA will gain in quality, as a result of which a more solid foundation for cumulative knowledge generation and well-informed policy decisions will also be created.

Hepatitis B virus: Where do we stand and what is the next step for eradication?

Hepatitis B (HB) virus (HBV) infection, which causes liver cirrhosis and hepatocellular carcinoma, is endemic worldwide. Hepatitis B vaccines became commercially available in the 1980s. The World Health Organization recommended the integration of the HB vaccine into the national immunisation programs in all countries. HBV prevention strategies are classified into three groups: (1) universal vaccination alone; (2) universal vaccination with screening of pregnant women plus HB immune globulin (HBIG) at birth; and (3) selective vaccination with screening of pregnant women plus HBIG at birth. Most low-income countries have adopted universal vaccine programs without screening of pregnant women. However, HB vaccines are not widely used in low-income countries. The Global Alliance for Vaccine and Immunization was launched in 2000, and by 2012, the global coverage of a three-dose HB vaccine had increased to 79%. The next challenges are to further increase the coverage rate, close the gap between recommendations and routine practices, approach high-risk individuals, screen and treat chronically infected individuals, and prevent breakthrough infections. To eradicate HBV infections, strenuous efforts are required to overcome socioeconomic barriers to the HB vaccine; this task is expected to take several decades to complete.

Delivering vaccines for the prevention of pneumonia - programmatic and financial issues

Pneumonia is the leading cause of morbidity and mortality in children younger than 5 years. Vaccines are available against the main bacterial pathogens Haemophilus influenzae type b and Streptococcus pneumoniae. There are also vaccines against measles and pertussis; diseases that can predispose a child to pneumonia. Partners such as the Global Alliance for Vaccines and Immunisation (GAVI), the Hib Initiative, the Accelerated Development and Introduction Plan for pneumococcal vaccines and the Measles Initiative, have accelerated the introduction of vaccines into developing countries. Whilst significant improvements in vaccine coverage have occurred globally over the past decade, there still remains an urgent need to scale-up key pneumonia protection and treatment interventions as identified in the Global Action Plan for the Prevention and Control of Pneumonia (GAPP). There is promise that global immunisation will continue to improve child survival. However, there are several challenges to vaccine implementation that must first be addressed, including: a lack of access to under-served and marginalised populations; inadequate planning and management; a lack of political commitment; weak monitoring and surveillance programmes and assured sustainable finance and supply of quality vaccines. There is an urgent need to increase global awareness of the devastation that pneumonia brings to the worlds poorest communities.

Implementing new health interventions in developing countries: why do we lose a decade or more?

BACKGROUND

It is unclear how long it takes for health interventions to transition from research and development (R&D) to being used against diseases prevalent in resource-poor countries. We undertook an analysis of the time required to begin implementation of four vaccines and three malaria interventions. We evaluated five milestones for each intervention, and assessed if the milestones were associated with beginning implementation.

METHODS

The authors screened World Health Organization (WHO) databases to determine the number of years between first regulatory approval of interventions, and countries beginning implementation. Descriptive analyses of temporal patterns and statistical analyses using logistic regression and Cox proportional hazard models were used to evaluate associations between five milestones and the beginning of implementation for each intervention. The milestones were: (A) presence of a coordinating group focused on the intervention; (B) availability of an intervention tailored to developing country health systems; (C) international financing commitment, and; (D) initial and (E) comprehensive WHO recommendations. Countries were categorized by World Bank income criteria.

RESULTS

Five years after regulatory approval, no low-income countries (LICs) had begun implementing any of the vaccines, increasing to an average of only 4% of LICs after 10 years. Each malaria intervention was used by an average of 7% of LICs after five years and 37% after 10 years. Four of the interventions had similar implementation rates to hepatitis B vaccine (HepB), while one was slower and one was faster than HepB. A financing commitment and initial WHO recommendation appeared to be temporally associated with the beginning of implementation. The initial recommendation from WHO was the only milestone associated in all statistical analyses with countries beginning implementation (relative rate = 1.97, P < 0.001).

CONCLUSIONS

Although possible that four milestones were not associated with countries beginning implementation, we propose an alternative interpretation; that the milestones were not realized early enough in each intervention's development to shorten the time to beginning implementation. We discuss a framework built upon existing literature for consideration during the development of future interventions. Identifying critical milestones and their timing relative to R&D, promises to help new interventions realize their intended public health impact more rapidly.

The prevalence and genotype of human papillomavirus on cervical samples from an Irish female population with external genital warts

The aim of this study was to determine the cervical genotype profile of females who presented to an STI Clinic with external genital warts (EGW); and to determine the potential vaccine coverage prior to the uptake of the HPV vaccines. Sixty-one cervical scrapings were taken from females aged 18-35 y who had external genital warts or a history of external genital warts. The resulting 50 samples that were positive for HPV-DNA were subjected to genotype identification. Forty-six of these samples had detectable genotypes by LIPA analysis and most (78%, 36/46) had multiple low risk (LR) and high risk (HR) genotypes on the cervix. Twenty-five of these samples (54%) had more than 1 HR genotype. Of the 36 patients who had any HR genotypes, 18 (50%) were identified to have the most oncogenic HPV genotypes, namely 16 and 18. Three of these samples had both 16 and 18 on the cervix. The presence of multiple HR genotypes on the majority of cervical samples from a self-referred population of females with EGW is presented. This study is of importance since persistent HR-HPV is the necessary risk factor in the development of precancerous and cancerous lesions of the cervix. Gardisil, the quadrivalent HPV vaccine would have been useful in the prevention of 28% (13/46) of these infections.

Identification of HBsAg-specific antibodies from a mammalian cell displayed full-length human antibody library of healthy immunized donor

Hepatitis B immunoglobulin (HBIG) is important in the management of hepatitis B virus (HBV) infection. Aiming to develop recombinant monoclonal antibodies as an alternative to HBIG, we report the successful identification of HBV surface antigen (HBsAg)-specific antibodies from a full-length human antibody library displayed on mammalian cell surface. Using total RNA of peripheral blood mononuclear cells of a natively immunized donor as template, the antibody repertoire was amplified. Combining four-way ligation and the Flp recombinase-mediated integration (Flp-In) system, we constructed a mammalian cell-based, fully human, full-length antibody display library in which each cell displayed only one kind of antibody molecule. By screening the cell library using fluorescence-activated cell sorting (FACS), eight cell clones that displayed HBsAg-specific antibodies on cell surfaces were identified. DNA sequence analysis of the antibody genes revealed three unique antibodies. FACS data indicated that fluorescent strength of expression (FSE), fluorescent strength of binding (FSB) and relative binding ability (RBA) were all different among them. These results demonstrated that by using our antibody mammalian display and screening platform, we can successfully identify antigen-specific antibodies from an immunized full-length antibody library. Therefore, this platform is very useful for the development of therapeutic antibodies.