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.

Experiences recruiting Indian worksites for an integrated health protection and health promotion randomized control trial in Maharashtra, India

This article provides an overview of the recruitment strategies utilized in the Mumbai Worksites Tobacco Control Study, a cluster randomized trial testing the effectiveness of an integrated tobacco control and occupational safety and health program in Indian manufacturing worksites. From June 2012 to June 2013, 20 companies were recruited. Companies were identified using association lists, referrals, internet searches and visits to industrial areas. Four hundred eighty companies were contacted to validate information, introduce the study and seek an in-person meeting with a company representative. Eighty-three company representatives agreed to meet. Of those 83 companies, 55 agreed to a formal 'pitch meeting' with key decision makers at the company. Seventy-seven recruitment 'pitches' were given, including multiple meetings in the same companies. If the company was interested, we obtained a letter of participation and employee roster. Based on this experience, recommendations are made that can help inform future researchers and practitioners wishing to recruit Indian worksites. When compared with recruitment of US manufacturing worksites, recruitment of Indian worksites lacked current industrial lists of companies to serve as a sampling frame, and required more in-person visits, incentives for control companies and more assurances around confidentiality to allow occupational safety and health experts into their worksite.

Withaferin A: a proteasomal inhibitor promotes healing after injury and exerts anabolic effect on osteoporotic bone

Withania somnifera or Ashwagandha is a medicinal herb of Ayurveda. Though the extract and purified molecules, withanolides, from this plant have been shown to have different pharmacological activities, their effect on bone formation has not been studied. Here, we show that one of the withanolide, withaferin A (WFA) acts as a proteasomal inhibitor (PI) and binds to specific catalytic β subunit of the 20S proteasome. It exerts positive effect on osteoblast by increasing osteoblast proliferation and differentiation. WFA increased expression of osteoblast-specific transcription factor and mineralizing genes, promoted osteoblast survival and suppressed inflammatory cytokines. In osteoclast, WFA treatment decreased osteoclast number directly by decreasing expression of tartarate-resistant acid phosphatase and receptor activator of nuclear factor kappa-B (RANK) and indirectly by decreasing osteoprotegrin/RANK ligand ratio. Our data show that in vitro treatment of WFA to calvarial osteoblast cells decreased expression of E3 ubiquitin ligase, Smad ubiquitin regulatory factor 2 (Smurf2), preventing degradation of Runt-related transcription factor 2 (RunX2) and relevant Smad proteins, which are phosphorylated by bone morphogenetic protein 2. Increased Smurf2 expression due to exogenous treatment of tumor necrosis factor α (TNFα) to primary osteoblast cells was decreased by WFA treatment. This was corroborated by using small interfering RNA against Smurf2. Further, WFA also blocked nuclear factor kappa-B (NF-kB) signaling as assessed by tumor necrosis factor stimulated nuclear translocation of p65-subunit of NF-kB. Overall data show that in vitro proteasome inhibition by WFA simultaneously promoted osteoblastogenesis by stabilizing RunX2 and suppressed osteoclast differentiation, by inhibiting osteoclastogenesis. Oral administration of WFA to osteopenic ovariectomized mice increased osteoprogenitor cells in the bone marrow and increased expression of osteogenic genes. WFA supplementation improved trabecular micro-architecture of the long bones, increased biomechanical strength parameters of the vertebra and femur, decreased bone turnover markers (osteocalcin and TNFα) and expression of skeletal osteoclastogenic genes. It also increased new bone formation and expression of osteogenic genes in the femur bone as compared with vehicle groups (Sham) and ovariectomy (OVx), Bortezomib (known PI), injectible parathyroid hormone and alendronate (FDA approved drugs). WFA promoted the process of cortical bone regeneration at drill-holes site in the femur mid-diaphysis region and cortical gap was bridged with woven bone within 11 days of both estrogen sufficient and deficient (ovariectomized, Ovx) mice. Together our data suggest that WFA stimulates bone formation by abrogating proteasomal machinery and provides knowledge base for its clinical evaluation as a bone anabolic agent.

Interaction of anionic compounds with gelatin. I: Binding studies

Even though gelatin is the most widely used polymeric excipient in pharmaceutical products, scant attention has been paid to its interaction with small organic molecules. The present work deals with the interaction of gelatin and four monosulfonated or monocarboxylated azo dyes having hydrocarbon moieties of different sizes. These dyes were used as models for anionic drugs, which make up a significant percentage of all new drugs. Most binding studies used ultrafiltration to separate free from bound dye, followed by spectrophotometric dye assays. One binding study was based on the shift in pH when a dye was added to gelatin solutions. All binding isotherms consisted of two linear segments. The initial segments, which start at the origin, represent the partitioning of the dyes between the dissolved gelatin and the aqueous buffer solution. They changed abruptly to horizontal plateaus, which represent the binding limit. Increases in pH from 5.00 to 7.00 reduced the binding of the sulfonated dyes but increased the binding of the carboxylated dye. At pH > or = 7.00, where even the carboxylic acid groups are fully ionized, the carboxylated dye and its sulfonated analog were bound to gelatin to the same extent. The binding of all dyes decreased with increasing temperature (i.e., the standard enthalpy of binding was negative), with a change of the solvent medium from water to 0.15 M ammonium acetate, and with decreasing size of the hydrocarbon moieties of the dyes. The binding of the dyes to gelatin was always reversible and the standard entropy change associated with it was negative.(ABSTRACT TRUNCATED AT 250 WORDS)

Interaction of anionic compounds with gelatin. II: Effect on some physicochemical properties of gelatin

The interaction of gelatin with four monosulfonated or monocarboxylated azo dyes was investigated by measuring the surface tension and intrinsic viscosity of gelatin solutions containing the dyes at different concentrations, the rigidity and melting point of their gels, and the moisture regain of their films. The dyes, which were used as models for anionic drugs, differed in the size of their aromatic hydrocarbon moieties. Surface tension measurements showed that the gelatin did not affect the critical micelle concentration of the free dyes and that the bound dyes increased the surface activity of the gelatin. The dyes reduced the intrinsic viscosity of gelatin by as much as 2/3. They also lowered the rigidity and the melting point of dilute gelatin gels and reduced the moisture regain of dry gelatin films. These changes became more pronounced with increasing dye concentrations. The effectiveness of the dyes in producing these changes increased with the size of their hydrocarbon moieties because, as had been shown in a previous study, increasingly larger hydrocarbon moieties increased the binding of the dyes to gelatin. At the pH of the measurements, which was 1.9 units below the isoelectric point of the gelatin, the gelatin was a cationic polyelectrolyte. Binding of the dye anions by ion pairing, hydrogen bonds, and other secondary valence forces rendered the gelatin less ionic and less hydrophilic, which accounts for the present observations.