Vaccination barriers and drivers in Romania: a focused ethnographic study

BACKGROUND

In 2016-18, a large measles outbreak occurred in Romania identified by pockets of sub-optimally vaccinated population groups in the country. The aim of the current study was to gain insight into barriers and drivers from the experience of measles vaccination from the perspectives of caregivers and their providers.

METHODS

Data were collected by non-participant observation of vaccination consultations and individual interviews with health workers and caregivers in eight Romanian clinics with high or low measles vaccination uptake. Romanian stakeholders were involved in all steps of the study. The findings of this study were discussed during a workshop with key stakeholders.

RESULTS

Over 400 h of observation and 161 interviews were conducted. A clear difference was found between clinics with high and low measles vaccination uptake which indicates that being aware of and following recommended practices for both vaccination service delivery and conveying vaccine recommendations to caregivers may have an impact on vaccine uptake. Barriers identified were related to shortcomings in following recommended practices for vaccination consultations by health workers (e.g. correctly assessing contraindications or providing enough information to allow an informed decision). These observations were largely confirmed in interviews with caregivers and revealed significant knowledge gaps.

CONCLUSIONS

The identification of key barriers provided an opportunity to design specific interventions to improve vaccination service delivery (e.g. mobile vaccination clinics, use of an electronic vaccination registry system for scheduling of appointments) and build capacity among health workers (e.g. guidance and supporting materials and training programmes).

Behavioral Communication Strategies for Global Epidemics: An Innovative Model for Public Health Education and Humanitarian Response

In response to a number of growing global health challenges, New York University and UNICEF designed a Behavioral Communication Strategies for Global Epidemics course that brings together United Nations professionals, government staff, and MPH (Master of Public Health) students to design innovative social behavior change communication (SBCC) strategies that address disease outbreaks and humanitarian challenges around the world. Applying a systems approach, participants in the course work on interdisciplinary teams to design strategies, develop skills, and engage in global learning. At the culmination of the course, all teams present strategies to UNICEF country offices for implementation. This innovative model for disease outbreak, public health education, and humanitarian response provides professionals with an opportunity to develop a wide range of competencies, including systems thinking, behavior change, and human-centered design and equips them with the necessary tools to develop more novel approaches to SBCC. As the number of outbreaks and humanitarian challenges increase each year, this format for learning can serve as a model for how professionals can effectively address these complex crises.

Threats to oral polio vaccine acceptance in Somalia: Polling in an outbreak

BACKGROUND

Using a survey conducted during the 2013-2014 polio outbreak in Somalia, this study examines attitudinal and knowledge-based threats to oral polio vaccine acceptance and commitment. Findings address a key gap, as most prior research focuses on endemic settings.

METHODS

Between November 19 and December 21, 2013, we conducted interviews among 2003 caregivers of children under 5 years in select districts at high risk for polio transmission. Within each district, sample was drawn via a multi-stage cluster design with random route household selection. We calculated the percentage of caregivers who could not confirm recent vaccination and those uncommitted to future vaccination. We compared these percentages among caregivers with varying knowledge and attitudes, focusing on variables identified as threats in endemic settings, using controlled and uncontrolled comparisons. We also examined absolute levels of threat variables.

RESULTS

Only 10% of caregivers could not confirm recent vaccination, but 32% were uncommitted to future vaccination. Being unvaccinated or uncommitted were related to multiple threat variables. For example, compared with relevant counterparts, caregivers were more likely to be unconfirmed and uncommitted if they did not trust vaccinators "a great deal" (unconfirmed: 9% vs. 2%; uncommitted: 49% vs. 28%), which is also true in endemic settings. Unlike endemic settings, symptom knowledge was related to commitment while rumor awareness was low and unrelated to past acceptance or commitment. Levels of trust and perceptions of OPV effectiveness were high, though perceptions of community support and awareness of logistics were lower.

CONCLUSIONS

As in endemic settings, outbreak responses will benefit from communications strategies focused on enhancing trust in vaccinators, institutions and the vaccine, alongside making community support visible. Disease facts may help motivate acceptance, and enhanced logistics information may help facilitate caregiver availability at the door. Quelling rumors early may be important to prevent them from becoming threats.

Placing Human Behavior at the Center of the Fight to Eradicate Polio: Lessons Learned and Their Application to Other Life-Saving Interventions

Today, acceptance of oral polio vaccine is the highest ever. Reaching this level of acceptance has depended on decades of engaging with communities, building trust amid extraordinary social contexts, and responding to the complex variables that trigger behavioral and social change. Drawing on both the successes and setbacks in the 28 years of the Global Polio Eradication Initiative (GPEI), this article articulates what happened when the GPEI began to pay more attention to the dynamics of human and social behavior change. Three particular lessons for other health and immunization programs can be drawn from the experience of GPEI: change begins from within (ie, success needs institutional recognition of the importance of human behavior), good data are not enough for good decision-making, and health workers are important agents of behavior change. These lessons should be harnessed and put into practice to build demand and trust for the last stages of polio eradication, as well as for other life-saving health interventions.

Threats to polio eradication in high-conflict areas in Pakistan and Nigeria: a polling study of caregivers of children younger than 5 years

BACKGROUND

Elimination of poliovirus from endemic countries is a crucial step in eradication; however, vaccination programmes in these areas face challenges, especially in regions with conflict. We analysed interviews with caregivers of children living in two polio-endemic countries to assess whether these challenges are largely operational or also driven by resistance or misinformation in the community.

METHODS

We designed and analysed polls based on face-to-face interviews of a random sample of parents and other caregivers of children younger than 5 years in regions of Pakistan and Nigeria at high risk for polio transmission. In both countries, the sample was drawn via a stratified multistage cluster design with random route household selection. The questionnaire covered awareness, knowledge, and attitudes about polio and oral polio vaccine (OPV), trust in vaccination efforts, and caregiver priorities for government action. We assessed experiences of caregivers in accessible higher-conflict areas and compared their knowledge and attitudes with those in lower-conflict areas. Differences were tested with two-sample t tests.

FINDINGS

The poll consisted of 3396 caregivers from Pakistan and 2629 from Nigeria. About a third of caregivers who responded in higher-conflict areas of Pakistan (Federally Administered Tribal Areas [FATA], 30%) and Nigeria (Borno, 33%) were unable to confirm that their child was vaccinated in the previous campaign. In FATA, 12% of caregivers reported that they were unaware of polio, and in Borno 12% of caregivers reported that vaccinators visited but their child did not receive the vaccine or they did not know whether the child was vaccinated. Additionally, caregivers in higher-conflict areas are less likely to hold beliefs about OPV that could motivate acceptance and are more likely to hold concerns than are caregivers in lower-conflict areas.

INTERPRETATION

Beyond the difficulties in reaching homes with OPV, challenges for vaccination programmes in higher-conflict areas extend to limited awareness, negative attitudes, and gaps in trust. Vaccination efforts might need to address underlying attitudes of caregivers through direct communications and the selection and training of local vaccinators.

FUNDING

Harvard T H Chan School of Public Health and UNICEF.

Health communication and vaccine hesitancy

Health communication is an evolving field. There is evidence that communication can be an effective tool, if utilized in a carefully planned and integrated strategy, to influence the behaviours of populations on a number of health issues, including vaccine hesitancy. Experience has shown that key points to take into account in devising and implementing a communication plan include: (i) it is necessary to be proactive; (ii) communication is a two-way process; (iii) knowledge is important but not enough to change behaviour; and (iv) communication tools are available and can be selected and used creatively to promote vaccine uptake. A communication strategy, incorporating an appropriate selection of the available communication tools, should be an integral part of every immunization programme, addressing the specific factors that influence hesitancy in the target populations.

Global polio eradication initiative: lessons learned and legacy

The world is on the verge of achieving global polio eradication. During >25 years of operations, the Global Polio Eradication Initiative (GPEI) has mobilized and trained millions of volunteers, social mobilizers, and health workers; accessed households untouched by other health initiatives; mapped and brought health interventions to chronically neglected and underserved communities; and established a standardized, real-time global surveillance and response capacity. It is important to document the lessons learned from polio eradication, especially because it is one of the largest ever global health initiatives. The health community has an obligation to ensure that these lessons and the knowledge generated are shared and contribute to real, sustained changes in our approach to global health. We have summarized what we believe are 10 leading lessons learned from the polio eradication initiative. We have the opportunity and obligation to build a better future by applying the lessons learned from GPEI and its infrastructure and unique functions to other global health priorities and initiatives. In so doing, we can extend the global public good gained by ending for all time one of the world's most devastating diseases by also ensuring that these investments provide public health dividends and benefits for years to come.

Polio eradication initiative in Afghanistan, 1997-2013

BACKGROUND

This article reviews the epidemiology of polio, acute flaccid paralysis (AFP) surveillance, and the implementation of supplemental immunization activities (SIAs) in Afghanistan from 1997 thru 2013.

METHODS

Published reports and unpublished national data on polio cases, AFP surveillance, and SIAs were analyzed. Recommendations from independent advisory groups and Afghan government informed the conclusions.

RESULTS

From 1997 thru 2013, the annual number of confirmed polio cases fluctuated from a low of 4 in 2004 to a high of 80 in 2011. Wild poliovirus types 2 and 3 were last reported in 1997 and 2010, respectively. Circulating vaccine-derived poliovirus type 2 emerged in 2009. AFP surveillance quality in children aged <15 years improved over time, achieving rates>8 per 100,000 population. Since 2001, at least 6 SIAs have been conducted annually.

CONCLUSIONS

Afghanistan has made progress moving closer to eliminating polio. The program struggles to reach all children because of management and accountability problems in the field, inaccessible populations, and inadequate social mobilization. Consequently, too many children are missed during SIAs. Afghanistan adopted a national emergency action plan in 2012 to address these issues, but national elimination will require consistent and complete implementation of proven strategies.

Characterization of thermosensitive chitosan gels for the sustained delivery of drugs

The aim of this study was to investigate the physical properties of a chitosan/glycerophosphate (GP) thermosensitive solution which gels at 37 degrees C and evaluate the in vitro release profiles of different model compounds. The gelation rate was dependent on the temperature and on the chitosan deacetylation degree. The solution containing 84%-deacetylated chitosan could be stored 3 months at 4 degrees C without apparent change in viscosity. The in vitro release profiles of the model compounds depended on the presence of GP in the chitosan solution, on their molecular weight and on the presence of lysozyme in the release media. They were not affected by the electrostatic charge of the model compound when present at low concentrations. During the first 4 h, the release was accompanied by a substantial loss of the gel weight which was mainly attributed to the leaching of water and excess GP. Scanning electron micrographs revealed that the solutions yield gels with a highly porous structure after 24 h of exposure to a continuous flow of phosphate buffered saline. These results indicate that the chitosan/GP thermosensitive solutions gel rapidly at body temperature, can remain in the sol state at 4 degrees C and can sustain the delivery of macromolecules.

Neurobehavioral tests as a medical surveillance procedure: applying evaluative criteria

Neurobehavioral impairment is among the earliest indicators of a toxic insult on the nervous system. Neurobehavioral tests measure behavior impairment by noninvasive procedures that assess various performance and personality changes. Neurobehavioral tests have been used on groups of workers included in epidemiologic research studies; however, their suitability for an ongoing medical surveillance program for workers exposed to neurotoxic agents has not been evaluated. In Ontario, Canada, a set of validity criteria must be met to determine whether a medical procedure may be prescribed for a specific medical surveillance program. The evaluative criteria are standards for judging the desirability of a procedure based on social values and scientific considerations. In this paper, various studies using neurobehavioral tests are reviewed, and the validity of using these procedures for medical surveillance is evaluated by applying the Ontario evaluation criteria. The conclusion is that neurobehavioral tests are useful for well-controlled, cross-sectional studies, but they do not yet meet the validity criteria for procedures prescribed in an ongoing medical surveillance program for workers exposed to neurotoxic agents.

New perspectives on use of thymic factors in immune deficiency

Current knowledge on the role of thymic factors in the immune response is inadequate and remains relatively primitive when compared with present technical possibilities for assessing lymphocyte subsets or cytokine interaction. New studies support the potential importance of thymic factors as regulators of immune interactions. Indirect evidence supports the concept that thymic factors may work at the level of IL-2. The functional identity of cells responsive to thymic factors and the relation of observed effects to cytokine network interactions need to be established. The use of thymic factors in the future will depend on the development of criteria to identify appropriate settings in which to use such factors and the implementation of appropriate measures of immune functional response.

The capillary transport system for free fatty acids in the heart

The nature of the process by which free fatty acids, which are tightly bound to albumin, traverse the endothelium of cardiac capillaries to reach the cardiac muscle cells, so that they are extracted to a net extent of approximately 40%, needs clarification. Previous studies have indicated that a membrane fatty acid-binding protein provides for carrier-mediated uptake of free fatty acids by isolated hepatocytes, cardiomyocytes, and jejunal mucosal cells. A monoclonal monospecific antibody was prepared against purified membrane fatty acid-binding protein from rat liver. Multiple-indicator dilution experiments were carried out in the isolated rat heart with labeled albumin, sucrose, and palmitate in the presence of control perfusate or perfusate containing either specific antibody or comparable nonspecific myeloma cell supernatant (each of the latter containing additional albumin, in identical concentrations). Analysis of the labeled-sucrose curves provided a permeability-surface area product for sucrose to which that for palmitate could be compared. In comparison with control supernatants, myeloma supernatant produced a minor inhibition of palmitate uptake, as a result of the increase in albumin concentration. The specific antibody, which contained identical albumin concentrations, produced a major inhibition of palmitate uptake, significantly greater than with the myeloma supernatant. The data indicate that the membrane fatty acid-binding protein mediates the transfer of free fatty acid across the endothelial cells of cardiac capillaries for presentation to heart muscle. Passive intramembrane lateral diffusion of palmitate could not provide an explanation for the findings.

Pigmented villonodular synovitis in a child

The authors present a case of pigmented villonodular synovitis (PVNS) in an adolescent with monarticular involvement of the ankle and without congenital anomalies or sibling involvement. Its rarity in the ankle and in childhood is discussed; a review of the clinical, radiological, and pathological features of PVNS is presented.

Flow-limited tracer oxygen distribution in the isolated perfused rat liver: effects of temperature and hematocrit

We used the multiple-indicator dilution technique to examine the kinetics of tracer oxygen distribution and uptake in the rat liver perfused in a nonrecirculating fashion with blood. 51Cr-labeled 18O2-saturated erythrocytes, labeled albumin, sucrose and water (the tracers for oxygen and vascular, interstitial and cellular references) were injected simultaneously into the portal vein. Timed anaerobic samples were collected from the hepatic vein and analyzed by mass spectrometry for relative 18O2 enrichment and radioactivity. In a set of experiments performed at 32 degrees C, oxygen uptake was substantially diminished; tracer oxygen profiles approached those expected for a completely recovered, flow-limited substance. At 37 degrees C, much larger tracer oxygen sequestration occurred. Experiments were carried out at each temperature at higher and lower hematocrit, and oxygen consumption at each temperature was found to be independent of hematocrit. The tissue space of distribution for tracer oxygen relative to the total sinusoidal vascular content was influenced by the hematocrit: it was smaller at higher hematocrit and larger at lower hematocrit, as expected. The derived partition coefficient of oxygen for liver cells relative to plasma (expressed in terms of the liver and plasma water spaces) was, on average, 2.62 ml/ml; it was independent of the hematocrit. Analysis of the indicator dilution experiments indicates that the tracer oxygen is distributed into tissue in a flow-limited rather than a barrier-limited fashion, and that with this, an ongoing concomitant intracellular sequestration of tracer can be seen.

Respiratory variables and exposure-effect relationships in isocyanate-exposed workers

Respiratory variables in 95 isocyanate workers and 37 control workers were compared. The exposed workers had a slightly higher frequency of cough and shortness of breath than the controls and a significantly lower frequency of family history of asthma, hay fever, and bronchitis. The isocyanate workers had slightly lower baseline lung function than the control workers but demonstrated significantly larger declines in their pulmonary function over the work shift. Both groups showed some intraday and intraweek variation in lung function. The changes in lung function over the work shift varied with different job categories, the largest changes occurring in finishing-area workers. A gradation of response was observed when exposure was categorized as nil, low, or high, but no exposure-effect relationships could be demonstrated by regression analysis of either area or personal results.