Factors associated with vaccine coverage improvements in Senegal between 2005 and 2019: a quantitative retrospective analysis

OBJECTIVE

Senegal has demonstrated catalytic improvements in national coverage rates for early childhood vaccination, despite lower development assistance for childhood vaccines in Senegal compared with other low-income and lower-middle income countries. Understanding factors associated with historical changes in childhood vaccine coverage in Senegal, as well as heterogeneities across its 14 regions, can highlight effective practices that might be adapted to improve vaccine coverage elsewhere.

DESIGN

Childhood vaccination coverage rates, demographic information and health system characteristics were identified from Senegal's Demographic and Health Surveys (DHS) and Senegal national reports for years 2005-2019. Multivariate logistic and linear regression analyses were performed to determine statistical associations of demographic and health system characteristics with respect to childhood vaccination coverage rates.

SETTING

The 14 administrative regions of Senegal were chosen for analysis.

PARTICIPANTS

DHS women's survey respondents with living children aged 12-23 months for survey years 2005-2019.

OUTCOME MEASURES

Immunisation with the third dose of the diphtheria-tetanus-pertussis vaccine (DTP3), widely used as a proxy for estimating immunisation coverage levels and the retention of children in the vaccine programme.

RESULTS

Factors associated with childhood vaccination coverage include urban residence (β=0.61, p=0.0157), female literacy (β=1.11, p=0.0007), skilled prenatal care (β=1.80, p<0.0001) and self-reported ease of access to care when sick, considering travel distance to a healthcare facility (β=-0.70, p=0.0009) and concerns over travelling alone (β=-1.08, p<0.0001). Higher coverage with less variability over time was reported in urban areas near the capital and the coast (p=0.076), with increased coverage in recent years in more rural and landlocked areas.

CONCLUSIONS

Childhood vaccination was more likely among children whose mothers had higher literacy, received skilled prenatal care and had perceived ease of access to care when sick. Overall, vaccination coverage is high in Senegal and disparities in coverage between regions have decreased significantly in recent years.

Critical success factors for high routine immunization performance: A case study of Nepal

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Nepal reported high and sustained immunization coverage compared to peers.

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National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building.

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Pro-vaccine messaging through various mediums, including Female Community Health Volunteers, which was tailored to local needs, generated public awareness.

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Cultural values fostered collective responsibility and community ownership of vaccine coverage.

Introduction

The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies drive catalytic improvements in vaccination coverage are not well established. To address this gap, we identified critical success factors that may have led to substantial improvements in routine childhood immunization coverage in Nepal from 2000 through 2019.

Methods

We identified Nepal as an exemplar in the delivery of early childhood immunization through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health post, and community level, we investigated factors that contributed to high and sustained vaccine coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data.

Results

The following success factors emerged: 1) Codification of health as a human right, - along with other vaccine-specific legislation - ensured the stability of vaccination programming; 2) National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building; 3) Pro-vaccine messaging through various mediums, which was tailored to local needs, generated public awareness; 4) Female Community Health Volunteers educated community members as trusted and compassionate neighbors; and 5) Cultural values fostered collective responsibility and community ownership of vaccine coverage.

Conclusion

This case study of Nepal suggests that the success of its national immunization program relied on the engagement and understanding of the beneficiaries. The immunization program was supported by consistent and reliable commitment, collaboration, awareness, and collective responsibility between the government, community, and partners. These networks are strengthened through a collective dedication to vaccination programming and a universal belief in health as a human right.

Critical success factors for routine immunization performance: A case study of Zambia 2000 to 2018

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This paper describes how policies and programs contributed to improved vaccine coverage in Zambia.

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Communication, coordination, and collaboration between implementing levels were imperative.

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Adjacent successes in health systems strengthening and governance were leveraged.

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Policies in Zambia include flexibility in implementation for tailored approaches in each district.

Introduction

The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies prove effective at driving coverage is not well-established. To address this gap, we identified critical success factors associated with advancing key policies and programs that may have led to the substantial changes in routine childhood immunization coverage in Zambia between 2000 and 2018.

Methods

We identified Zambia as an exemplar in the delivery of childhood vaccines through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national and subnational levels, we investigated factors that contributed to high and sustained vaccination coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data.

Results

The following success factors emerged: 1) the Inter-agency Coordinating Committee was strengthened for long-term engagement which, complemented by the Zambia Immunization Technical Advisory Group, is valued by the government and integrated into national-level decision-making; 2) the Ministry of Health improved the coordination of data collection and review for informed decision-making across all levels; 3) Regional multi-actor committees identified development priorities, strategies, and funding, and iteratively adjusted policies to account for facilitators, barriers, and lessons learned; 4) Vaccine messaging was disseminated through multiple channels, including the media and community leaders, increasing trust in the government by community members; 5) The Zambia Ministry of Health and Churches Health Association of Zambia formalized a long-term organizational relationship to leverage the strengths of faith-based organizations; and 6) Neighborhood Health Committees spearheaded community-driven strategies via community action planning and ultimately strengthened the link between communities and health facilities.

Conclusion

Broader health systems strengthening and strong partnerships between various levels of the government, communities, and external organizations were critical factors that accelerated vaccine coverage in Zambia. These partnerships were leveraged to strengthen the overall health system and healthcare governance.

Students' preferences for returning to colleges and universities during the COVID-19 pandemic: A discrete choice experiment

IMPORTANCE

When an emerging infectious disease outbreak occurs, such as COVID-19, institutions of higher education (IHEs) must weigh decisions about how to operate their campuses. These decisions entail whether campuses should remain open, how courses should be delivered (in-person, online, or a mixture of the two), and what safety plans should be enacted for those on campus. These issues have weighed heavily on campus administrators during the on-going COVID-19 pandemic. However, there is still limited knowledge about how such decisions affect students' enrollment decisions and campus safety in practice when considering compliance.

OBJECTIVES

To assess 1) students' willingness to comply with health protocols and contrast their perception of their classmates' compliance, 2) whether students prefer in-person or online learning during a pandemic, and 3) the importance weights of different aspects of campus operations (i.e., modes of course delivery and safety plans) for students when they decide to enroll or defer.

DESIGN SETTING AND PARTICIPANTS

An internet-based survey of college students took place from June 25, 2020 to July 10, 2020. Participants included 398 industrial engineering students at the Georgia Institute of Technology, a medium-size public university in Atlanta, Georgia. The survey included a discrete choice experiment with questions that asked students to choose whether to enroll or defer when presented with hypothetical scenarios related to Fall 2020 modes of course delivery and aspects of campus safety. The survey also asked students about expected compliance with health protocols, whether they preferred in-person or online courses, and sociodemographic information.

MAIN OUTCOMES AND MEASURES

We examine students' willingness to comply with potential health protocols. We estimated logistic regression models to infer significant factors that lead to a student's choice between in-person and online learning. Additionally, we estimated discrete choice models to infer the importance of different modes of course delivery and safety measures to students when deciding to enroll or defer.

RESULTS

The survey response rate was 20.8%. A latent class model showed three classes of students: those who were "low-concern" (comprising a 29% expected share of the sample), those who were "moderate-concern" (54%) and those who were "high-concern" (17%). We found that scenarios that offered an on-campus experience with large classes delivered online and small classes delivered in-person, strict safety protocols in terms of mask-wearing, testing, and residence halls, and lenient safety protocols in terms of social gatherings were broadly the scenarios with the highest expected enrollment probabilities. The decision to enroll or defer for all students was largely determined by the mode of delivery for courses and the safety measures on campus around COVID-19 testing and mask-wearing. A logistic regression model showed that a higher perceived risk of infection of COVID-19, a more suitable home environment, being older, and being less risk-seeking were significant factors for a person to choose online learning. Students stated for themselves and their classmates that they would comply with some but not all health protocols against COVID-19, especially those limiting social gatherings.

CONCLUSIONS AND RELEVANCE

The majority of students indicated a preference to enroll during the COVID-19 pandemic so long as sufficient safety measures were put in place and all classes were not entirely in-person. As IHEs consider different options for campus operations during pandemics, they should consider the heterogeneous preferences among their students. Offering flexibility in course modes may be a way to appeal to many students who vary in terms of their concern about the pandemic. At the same time, since students overall preferred some safety measures placed around mask-wearing and COVID-19 testing on campus, IHEs may want to recommend or require wearing masks and doing some surveillance tests for all students, faculty, and staff. Students were expecting themselves and their fellow classmates to comply with some but not all health protocols, which may help IHEs identify protocols that need more education and awareness, like limits on social gatherings and the practice of social distancing at social gatherings.

Health spending and vaccination coverage in low-income countries

INTRODUCTION

Routine immunisation is a cost-effective way to save lives and protect people from disease. Some low-income countries (LIC) achieved remarkable success in childhood immunisation. Yet, previous studies comparing the relationship between economic growth and health spending with vaccination coverage have been limited. We investigated these relationships among LIC to understand what financial changes lead to childhood immunisation changes.

METHODS

We identified which financial indicators were significant predictors of vaccination coverage in LIC by fitting regression models for several vaccines, controlling for population density, land area and female years of education. We then identified LIC with high vaccination coverage (LIC+) and compared their economic and health spending trends with other LIC (LIC-) and lower-middle income countries. We used cross-country multi-year regressions with mixed-effects to test financial indicators' rate of change. We conducted statistical tests to verify if financial trends of LIC+ were significantly different from LIC-.

RESULTS

During 2014-2018, gross domestic product per capita (p=0.67-0.95, range given by tests with different vaccines), total/private health spending per capita (p=0.57-0.97, p=0.32-0.57) and aggregated development assistance for health (DAH) per capita (p=0.38-0.86) were not significant predictors of vaccination coverage in LIC. Government health spending per capita (p=0.022-0.073) and total/government spending per birth on routine immunisation vaccines (p=0.0007-0.029, p=0.016-0.052) were significant positive predictors of vaccination coverage. From 2000 to 2016, LIC+ increased government health spending per capita by US$0.30 per year, while LIC- decreased by US$0.16 (significant difference, p<0.0001). From 2006 to 2017, LIC+ increased government spending per birth on routine immunisation vaccines by US$0.22 per year, while LIC- increased by US$0.10 (p<0.0093).

CONCLUSION

Vaccination coverage success of some LIC was not explained by economic development, total health spending nor aggregated DAH. Vaccination coverage success of LIC+ was associated with increasing government health spending particularly in routine immunisation vaccines.

Angiotensin II induces phenotype-dependent apoptosis in vascular smooth muscle cells

Angiotensin II regulates vascular structure through growth and apoptosis, with implications in pathophysiology. Subtypes of vascular smooth muscle cells with specific morphology, growth, or apoptotic features have been isolated. Here, we investigated the effects of angiotensin II on apoptosis of 2 morphologically different rat aortic smooth muscle cell phenotypes. Spindle and epithelioid cell lines cultured under low serum conditions were stimulated by angiotensin II. Responsiveness was evaluated by calcium signaling. In both phenotypes, an angiotensin II type 1 receptor-mediated transient intracellular calcium peak arose from intracellular pools. However, a sustained nifedipine-sensitive calcium entry occurred specifically in epithelioid cells. Angiotensin II did not impair spindle cell survival, whereas a delayed reduction in cell number occurred in epithelioid cells. Cell death through apoptosis was characterized by cellular and nuclear morphology. Consistently, DNA fragmentation, evaluated by biochemical quantification, nuclei staining, and ladders, and caspase 3-like activity were promoted by angiotensin II in epithelioid cells. Kinetics of annexin V binding showed that apoptosis was a delayed process. Angiotensin II-induced apoptosis of epithelioid cells was prevented by angiotensin II type 1 but not type 2 receptor antagonists and was inhibited by a calcium chelator or calcium antagonist. Conversely, epithelioid cell apoptosis could be induced by a calcium ionophore. Thus, the death signaling promoted by angiotensin II in epithelioid cells involves type 1 receptor-mediated calcium entry. These data suggest that angiotensin II can promote angiotensin II type 1 receptor-mediated apoptosis in vascular smooth muscle cells, depending on their phenotype. This process may play a role in vascular remodeling in cardiovascular diseases.

Chlamydia pneumoniae induces interleukin-10 production that down-regulates major histocompatibility complex class I expression

Recently, it was demonstrated that CD8(+) T cells are important for the response against Chlamydia pneumoniae. By use of the human monocytic cell line U937 and human monocytes taken from peripheral blood, we investigated the effect of infection on various molecules critical for CD8(+) T cell function. A strong secretion of interleukin (IL)-10 by infected cells was observed, together with an inhibited expression of major histocompatibility complex (MHC) class I antigens, but without significant alteration of tumor growth factor-beta secretion or MHC class II expression. Recombinant IL-10 added to uninfected U937 cells decreased the expression of MHC class I, whereas blocking antibodies to IL-10 and its receptor abolished the C. pneumoniae-induced inhibition of MHC class I expression. Analysis of our data provides evidence that IL-10 secretion induced by C. pneumoniae infection of monocytic cells down-regulates the expression of MHC class I molecules and thereby might reduce the presentation of bacterial epitopes by MHC. This would decrease the ability of CD8(+) T cells to eliminate infected cells.