Aaron S. Wallace

Experiences with provider and parental attitudes and practices regarding the administration of multiple injections during infant vaccination visits: lessons for vaccine introduction.

INTRODUCTION An increasing proportion of childhood immunization visits include administration of multiple injections. Future introduction of vaccines to protect against multiple diseases will further increase the number of injections at routine immunization childhood visits, particularly in developing countries that are still scaling up introductions. Parental and healthcare provider attitudes toward multiple injections may affect acceptance of recommended vaccines, and understanding these attitudes may help to inform critical decisions about vaccine introduction. METHODS We conducted a systematic review of the literature to examine factors underlying reported parental and healthcare provider concerns and practices related to administration of multiple injections during childhood vaccination visits. RESULTS Forty-four articles were identified; 42 (95%) were from high income countries, including 27 (61%) from the USA. Providers and parents report concerns about multiple injections, which tend to increase with increasing numbers of injections. Common parental and provider concerns included apprehension about the pain experienced by the child, worry about potential side effects, and uncertainty about vaccine effectiveness. Multiple studies reported that a positive provider recommendation to the parent and a high level of concern about the severity of the target disease were significantly associated with parental acceptance of all injections. Providers often significantly overestimated parental concerns about multiple injections. DISCUSSION Providers may play a critical role in the decision for a child to receive all recommended injections. Their overestimation of parental concerns may lead them to postpone recommended vaccinations, which may result in extra visits and delayed vaccination. More research is needed on interventions to overcome provider and parental concern about multiple injections, particularly in developing countries.

Experiences Integrating Delivery of Maternal and Child Health Services With Childhood Immunization Programs: Systematic Review Update

BACKGROUND The World Health Organization and the United Nations Childrens Fund promote integration of maternal and child health (MCH) and immunization services as a strategy to strengthen immunization programs. We updated our previous review of integrated programs and reviewed reports of integration of MCH services with immunization programs at the service delivery level. METHODS Published and unpublished reports of interventions integrating MCH and immunization service delivery were reviewed by searching journal databases and Web sites and by contacting organizations. RESULTS Among 27 integrated activities, interventions included hearing screening, human immunodeficiency virus services, vitamin A supplementation, deworming tablet administration, malaria treatment, bednet distribution, family planning, growth monitoring, and health education. When reported, linked intervention coverage increased, though not to the level of the corresponding immunization coverage in all cases. Logistical difficulties, time-intensive interventions ill suited for campaign delivery, concern for harming existing services, inadequate overlap of target age groups, and low immunization coverage were identified as challenges. CONCLUSIONS Results of this review reinforce our 2005 review findings, including importance of intervention compatibility and focus on immunization program strength. Ensuring proper planning and awareness of compatibility of service delivery requirements were found to be important. The review revealed gaps in information about costs, comparison to vertical delivery, and impact on all integrated interventions that future studies should aim to address.

Evaluation of using routine infant immunization visits to identify and follow-up HIV-exposed infants and their mothers in Tanzania.

Background:Without treatment, approximately half of HIV-infected infants die by age 2 years, and 80% die before age 5 years. Early identification of HIV-infected and HIV-exposed infants provides opportunities for life-saving interventions. We evaluated integration of HIV-related services with routine infant immunization in Tanzania. Methods:During April 2009 to March 2010, at 4 urban and 4 rural sites, mothers’ HIV status was determined at first-month immunization using antenatal cards. HIV-exposed infants were offered HIV testing and follow-up care. Impact of integrated service delivery was assessed by comparing average monthly vaccine doses administered during the study period and a 2-year baseline period; acceptance was assessed by interviewing mothers and service providers. Findings:During 7569 visits, 308 HIV-exposed infants were identified and registered; of these, 290 (94%) were tested, 15 (5%) were HIV infected. At urban sites, first-month vaccine doses remained stable (+2% for pentavalent vaccine and -4% for polio vaccine), and vaccine doses given later in life (pentavalent, polio, and measles) increased 12%, 8%, and 11%, respectively. At rural sites, first-month vaccine doses decreased 33% and 35% and vaccine doses given later in life decreased 23%, 28%, and 28%. Mothers and service providers generally favored integrated services; however, HIV-related stigma and inadequate confidentiality controls of HIV testing were identified, particularly at rural sites. Interpretation:Integration of HIV-related services at immunization visits identified HIV-exposed infants, HIV-infected infants, and HIV-infected mothers; however, decreases in vaccine doses administered at rural sites were concerning. HIV-related service integration with immunization visits needs careful monitoring to ensure optimum vaccine delivery.

Implementation and evaluation of the Reaching Every District (RED) strategy in Assam, India, 2005–2008☆

In 2005, UNICEF and the Centers for Disease Control and Prevention implemented and evaluated the Reaching Every District (RED) approach, an intervention designed to improve key components of immunization services including planning, outreach, community mobilization, supervision, and monitoring, in select districts of Assam, India. Two intervention and 3 comparison districts were selected for a 2-year evaluation trial. In intervention districts, immunization staff received comprehensive training and ongoing supervision by a fulltime consultant, and regular monitoring of progress was conducted. Population-based vaccination coverage surveys were conducted at baseline and 2 years after the start of implementation in the 5 districts. Post-intervention process indicators were systematically collected and focus group discussions were held. At follow-up, children in both the intervention and comparison districts were twice as likely to be fully vaccinated as they were at baseline. However, sites that received intervention training were better performing than those that did not, as measured by process indicators, including a higher number of outreach visits planned and held (p=0.02), having a monitoring chart (p<0.01), and correctly calculating dropout (p<0.01). The number of supervisory visits was significantly and positively associated with other key process indicators. Although coverage did not differ significantly between intervention and comparison districts, among individual districts, process data indicate significant improvements in program quality in the intervention districts. Further studies are needed to determine if the improved process indicators have sustainable impact on maintaining improvements in coverage.

Community and Health Worker Perceptions and Preferences Regarding Integration of Other Health Services With Routine Vaccinations: Four Case Studies

BACKGROUND Integration of routine vaccination and other maternal and child health services is becoming more common and the services being integrated more diverse. Yet knowledge gaps remain regarding community members and health workers acceptance, priorities, and concerns related to integration. METHODS Qualitative health worker interviews and community focus groups were conducted in 4 African countries (Kenya, Mali, Ethiopia, and Cameroon). RESULTS Integration was generally well accepted by both community members and health workers. Most integrated services were perceived positively by the communities, although perceptions around socially sensitive services (eg, family planning and human immunodeficiency virus) differed by country. Integration benefits reported by both community members and health workers across countries included opportunity to receive multiple services at one visit, time and transportation cost savings, increased service utilization, maximized health worker efficiency, and reduced reporting requirements. Concerns related to integration included being labor intensive, inadequate staff to implement, inadequately trained staff, in addition to a number of more broad health system issues (eg, stockouts, wait times). CONCLUSIONS Communities generally supported integration, and integrated services may have the potential to increase service utilization and possibly even reduce the stigma of certain services. Some concerns expressed related to health system issues rather than integration, per se, and should be addressed as part of a wider approach to improve health services. Improved planning and patient flow and increasing the number and training of health staff may help to mitigate logistical challenges of integrating services.

Evaluation of economic costs of a measles outbreak and outbreak response activities in Keffa Zone, Ethiopia

OBJECTIVE To estimate the economic impact of a measles outbreak and response activities that occurred in Keffa Zone, Ethiopia with 5257 reported cases during October 1, 2011-April 8, 2012, using the health sector and household perspectives. METHODS We collected cost input data through interviews and record reviews with government and partner agency staff and through a survey of 100 measles cases-patients and their caretakers. We used cost input data to estimate the financial and opportunity costs of the following outbreak and response activities: investigation, treatment, case management, active surveillance, immunization campaigns, and immunization system strengthening. FINDINGS The economic cost of the outbreak and response was 758,869 United States dollars (US

Limitations of Using Administratively Reported Immunization Data for Monitoring Routine Immunization System Performance in Nigeria

), including the opportunity cost of US

Strengthening Evidence-Based Planning of Integrated Health Service Delivery Through Local Measures of Health Intervention Delivery Times

327,545 (US

Vaccine wastage in Nigeria: An assessment of wastage rates and related vaccinator knowledge, attitudes and practices

62.31/case) and financial cost of US

Acceptance of the Administration of Multiple Injectable Vaccines in a Single Immunization Visit in Albania

431,324 (US