The Advisory Committee on Immunization Practices' Recommendation for Use of Moderna COVID-19 Vaccine in Adults Aged ≥18 Years and Considerations for Extended Intervals for Administration of Primary Series Doses of mRNA COVID-19 Vaccines - United States, February 2022.

The mRNA-1273 (Moderna) COVID-19 vaccine is a lipid nanoparticle-encapsulated, nucleoside-modified mRNA vaccine encoding the stabilized prefusion spike glycoprotein of SARS-CoV-2, the virus that causes COVID-19. During December 2020, the vaccine was granted Emergency Use Authorization (EUA) by the Food and Drug Administration (FDA), and the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use among persons aged ≥18 years (1), which was adopted by CDC. During December 19, 2020-January 30, 2022, approximately 204 million doses of Moderna COVID-19 vaccine were administered in the United States (2) as a primary series of 2 intramuscular doses (100 µg [0.5 mL] each) 4 weeks apart. On January 31, 2022, FDA approved a Biologics License Application (BLA) for use of the Moderna COVID-19 vaccine (Spikevax, ModernaTX, Inc.) in persons aged ≥18 years (3). On February 4, 2022, the ACIP COVID-19 Vaccines Work Group conclusions regarding recommendations for the use of the Moderna COVID-19 vaccine were presented to ACIP at a public meeting. The Work Group's deliberations were based on the Evidence to Recommendation (EtR) Framework,* which incorporates the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach† to rank evidence quality. In addition to initial clinical trial data, ACIP considered new information gathered in the 12 months since issuance of the interim recommendations, including additional follow-up time in the clinical trial, real-world vaccine effectiveness studies, and postauthorization vaccine safety monitoring. ACIP also considered comparisons of mRNA vaccine effectiveness and safety in real-world settings when first doses were administered 8 weeks apart instead of the original intervals used in clinical trials (3 weeks for BNT162b2 [Pfizer-BioNTech] COVID-19 vaccine and 4 weeks for Moderna COVID-19 vaccine). Based on this evidence, CDC has provided guidance that an 8-week interval might be optimal for some adolescents and adults. The additional information gathered since the issuance of the interim recommendations increased certainty that the benefits of preventing symptomatic and asymptomatic SARS-CoV-2 infection, hospitalization, and death outweigh vaccine-associated risks of the Moderna COVID-19 vaccine. On February 4, 2022, ACIP modified its interim recommendation to a standard recommendation§ for use of the fully licensed Moderna COVID-19 vaccine in persons aged ≥18 years.

Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger - United States, 2022.

At its November 2021 meeting, the Advisory Committee on Immunization Practices* (ACIP) approved the Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger-United States, 2022. The 2022 child and adolescent immunization schedule, found on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules), summarizes ACIP recommendations, including several changes from the 2021 immunization schedule† on the cover page, tables, and notes. The 2022 child and adolescent schedule also includes a newly created appendix that lists the contraindications and precautions for all vaccine types in the schedule. Health care providers are advised to use the tables, notes, and appendix together. This immunization schedule is recommended by ACIP (https://www.cdc.gov/vaccines/acip) and approved by CDC (https://www.cdc.gov), the American Academy of Pediatrics (https://www.aap.org), the American Academy of Family Physicians (https://www.aafp.org), the American College of Obstetricians and Gynecologists (http://www.acog.org), the American College of Nurse-Midwives (https://www.midwife.org), the American Academy of Physician Associates (https://www.aapa.org), and the National Association of Pediatric Nurse Practitioners (https://www.napnap.org).

Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2022.

At its November 2021 meeting, the Advisory Committee on Immunization Practices* (ACIP) approved the Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2022. The 2022 adult immunization schedule summarizes ACIP recommendations, including several changes to the cover page, tables, and notes from the 2021 immunization schedule.† In addition, the 2022 adult immunization schedule provides an appendix that lists the contraindications to and precautions for all routinely recommended vaccines in the schedule. This schedule can be found on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules). Health care providers are advised to use the cover page, tables, notes, and appendix together. This adult immunization schedule is recommended by ACIP (https://www.cdc.gov/vaccines/acip) and approved by CDC (https://www.cdc.gov), the American College of Physicians (https://www.acponline.org), the American Academy of Family Physicians (https://www.aafp.org), the American College of Obstetricians and Gynecologists (https://www.acog.org), the American College of Nurse-Midwives (https://www.midwife.org), the American Academy of Physician Associates (https://www.aapa.org), and the Society for Healthcare Epidemiology of America (https://www.shea-online.org).

Antigen Test Positivity After COVID-19 Isolation - Yukon-Kuskokwim Delta Region, Alaska, January-February 2022.

Isolation is recommended during acute infection with SARS-CoV-2, the virus that causes COVID-19, but the duration of infectiousness varies among individual persons. Rapid antigen test results have been correlated with detection of viable virus (1-3) and might inform isolation guidance, but data are limited for the recently emerged SARS-CoV-2 B.1.1.529 (Omicron) variant. On January 5, 2022, the Yukon-Kuskokwim Health Corporation (YKHC) recommended that persons with SARS-CoV-2 infection isolate for 10 days after symptom onset (or, for asymptomatic persons, 10 days after a positive nucleic acid amplification or antigen test result). However, isolation could end after 5-9 days if symptoms were resolving or absent, fever was absent for ≥24 hours without fever-reducing medications, and an Abbott BinaxNOW COVID-19 Ag (BinaxNOW) rapid antigen test result was negative. Antigen test results and associated individual characteristics were analyzed among 3,502 infections reported to YKHC during January 1-February 9, 2022. After 5-9 days, 396 of 729 persons evaluated (54.3%) had a positive antigen test result, with a declining percentage positive over time. In a multivariable model, a positive antigen test result was more likely after 5 days compared with 9 days (adjusted odds ratio [aOR] = 6.39) or after symptomatic infection (aOR = 9.63), and less likely after previous infection (aOR = 0.30), receipt of a primary COVID-19 vaccination series (aOR = 0.60), or after both previous infection and receipt of a primary COVID-19 vaccination series (aOR = 0.17). Antigen tests might be a useful tool to guide recommendations for isolation after SARS-CoV-2 infection. During the 10 days after infection, persons might be infectious to others and are recommended to wear a well-fitting mask when around others, even if ending isolation after 5 days.

Use of Ebola Vaccine: Expansion of Recommendations of the Advisory Committee on Immunization Practices To Include Two Additional Populations - United States, 2021.

On December 19, 2019, the Food and Drug Administration (FDA) approved rVSVΔG-ZEBOV-GP Ebola vaccine (ERVEBO, Merck) for the prevention of Ebola virus disease (EVD) caused by infection with Ebola virus, species Zaire ebolavirus, in adults aged ≥18 years. In February 2020, the Advisory Committee on Immunization Practices (ACIP) recommended preexposure vaccination with ERVEBO for adults aged ≥18 years in the United States who are at highest risk for potential occupational exposure to Ebola virus because they are responding to an outbreak of EVD, work as health care personnel at federally designated Ebola treatment centers in the United States, or work as laboratorians or other staff members at biosafety level 4 facilities in the United States (1).

Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2022.

In 2021, 20-valent pneumococcal conjugate vaccine (PCV) (PCV20) (Wyeth Pharmaceuticals LLC, a subsidiary of Pfizer Inc.) and 15-valent PCV (PCV15) (Merck Sharp & Dohme Corp.) were licensed by the Food and Drug Administration for adults aged ≥18 years, based on studies that compared antibody responses to PCV20 and PCV15 with those to 13-valent PCV (PCV13) (Wyeth Pharmaceuticals LLC, a subsidiary of Pfizer Inc.). Antibody responses to two additional serotypes included in PCV15 were compared to corresponding responses after PCV13 vaccination, and antibody responses to seven additional serotypes included in PCV20 were compared with those to the 23-valent pneumococcal polysaccharide vaccine (PPSV23) (Merck Sharp & Dohme Corp.). On October 20, 2021, the Advisory Committee on Immunization Practices (ACIP) recommended use of either PCV20 alone or PCV15 in series with PPSV23 for all adults aged ≥65 years, and for adults aged 19-64 years with certain underlying medical conditions or other risk factors* who have not previously received a PCV or whose previous vaccination history is unknown. ACIP employed the Evidence to Recommendation (EtR) framework,† using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE)§ approach to guide its deliberations regarding use of these vaccines. Before this, PCV13 and PPSV23 were recommended for use for U.S. adults and the recommendations varied by age and risk groups. This was simplified in the new recommendations.

Increasing Preparedness for Extreme Events using Plausibility-Based Scenario Planning: Lessons from COVID-19.

A striking feature of COVID-19 is many countries' low level of preparedness for it, despite pandemics being a known threat. This raises a question as to the reasons for this underpreparedness. While preparedness should have better reflected pandemics' long-run inevitability and potentially catastrophic impact, government-planning horizons are short term, and the attentiveness of policymakers is bounded and subject to multiple demands. Preparedness is therefore affected by the fundamental uncertainty surrounding the exact nature, timing, and impact of a pandemic. While a subjective probability is attributable to such an event's occurrence, just like it is any other, if founded on scant knowledge and perceived as being low it may inhibit preparedness. Under such circumstances, preparedness may be better served by a focus on plausibility. Moreover, any tendency for policymakers to disregard highly uncertain, low-probability, yet highly impactful events of this type is exacerbated by their "fat-tailed" distribution, which obscures their potential extremity. This article considers how plausibility-based scenario planning can increase preparedness for extreme events like a global pandemic, thereby reducing overconfidence in continued business-as-usual in their face, and emphasizing precaution in their wake. In so doing, the article contributes to what in this journal has recently been called "type B," "generic and fundamental" risk science, which is concerned with identifying better ways to present and communicate uncertainties. In focusing on plausibility-based scenario planning, the article highlights a method seldom previously discussed in relation to risk science, yet one that can contribute much to this type B component of it.

The Project Appropriate Birth and a reduction in caesarean section rates: an analysis using the Robson classification system.

OBJECTIVE: The objective of this study was to assess caesarean section (CS) rates before and after the implementation of the Project Appropriate Birth (PPA), based on the Robson ten group classification system. DESIGN: A before-and-after study. SETTING: Maternity hospital in South Brazil. POPULATION: All pregnant women attending from April 2016 to April 2017 (period 1, pre-implementation of PPA) and from June 2017 to June 2018 (period 2, post-implementation of PPA). METHODS: Maternal and obstetric characteristics were evaluated, including Robson's classification, based on the characteristics of pregnancy and childbirth. A chi-square test and crude and adjusted relative rates were used to analyse the study variables. The significance level was set at 5%. MAIN OUTCOME MEASURES: The CS rate for each group, their contribution to the overall CS rate and the differences in these contributions before and after PPA implementation. RESULTS: The CS rates decreased from 62.4 to 55.6%, which represented a 10.9% reduction after the implementation of the PPA. Pregnant women in Robson classification groups 1-4 had a 21.4% reduction in CS rates, ranging from 49.1 to 38.6%. The greatest contributors to the overall CS rates were group 5 and group 2, accounting for more than 60% of the CS deliveries. CONCLUSION: The study results suggest that Project Appropriate Birth had an impact on the reduction of CS rates, especially in Robson classification groups 1 through 4, which indicates that providing mothers with evidence-based interventions for labour and childbirth assistance contributed to reduce CS rates. TWEETABLE ABSTRACT: The Project Appropriate Birth is an innovative project that has demonstrated promising results, suggesting that interventions based on scientific evidence can lead to real changes in childbirth care, contributing to reduce CS rates. The aim of the PPA is to promote activities to improve childbirth care and encourage vaginal delivery. In this study, 6238 pregnant women admitted to the hospital for delivery were included and classified into one of the Robson 10-group classification. Findings revealed a 10.9% reduction in the overall CS rate and a 21.4% reduction for pregnant women in Robson classification groups 1 through 4, after the implementation of the PPA.

What is an appropriate caesarean delivery rate for China: a multicentre survey.

OBJECTIVE: To assess the current status of caesarean delivery (CD) in China, propose reference CD rates for China overall, and by regions, investigate the main indications for CDs and identify possible areas for safe reduction. DESIGN: A multicentre cross-sectional study. SETTING: A total of 94 hospitals across 23 provinces in China. POPULATION: A total of 73 977 randomly selected deliveries. METHODS: We used a modified Robson classification to characterise CDs in subgroups and by regions, and the World Health Organization (WHO) C-Model to calculate reference CD rates. MAIN OUTCOME MEASURES: CD rates in China. RESULTS: In 2015-2016, the overall CD rate in China was 38.9% (95% CI 38.6-39.3%). Considering the obstetric characteristics of the population, the multivariable model-based reference CD rate was estimated at 28.5% (95% CI 28.3-28.8%). Accordingly, an absolute reduction of 10.4% (or 26.7% relative reduction) may be considered. The CD rate varied substantially by region. Previous CD was the most common indication in all regions, accounting for 38.2% of all CDs, followed by maternal request (9.8%), labour dystocia (8.3%), fetal distress (7.7%) and malpresentation (7.6%). Overall, 12.7% of women had prelabour CDs, contributing to 32.8% of the total CDs. CONCLUSIONS: Nearly 39% of births were delivered by caesarean in China but a reduction of this rate by a quarter may be considered attainable. Repeat CD contributed more than one-third of the total CDs. Given the large variation in maternal characteristics, region-specific or even hospital-specific reference CD rates are needed for precision management of CD. TWEETABLE ABSTRACT: The caesarean rate in 2015-2016 in China was 38.9%, whereas the reference rate was 28.5%.

Health care providers' awareness of breastfeeding practice recommendations during COVID-19 pandemic and associated factors in Northwest Ethiopia, 2021: A multicenter study.

BACKGROUND: Prevention of coronavirus disease 2019 (COVID-19) transmission to newborns is one of the basic components of perinatal care in the era of the COVID-19 pandemic. As such, scientific evidence is compulsory for evidence-based practices. However, there was a scarcity of evidence on health care providers' awareness of breastfeeding practice recommendations during the COVID-19 pandemic in Ethiopia, particularly in the study setting. OBJECTIVE: The study aimed at assessing healthcare providers' awareness of breastfeeding practice recommendations during the COVID-19 pandemic and associated factors among healthcare providers in northwest Ethiopia, 2021. METHODS: A multicenter cross-sectional study was conducted among 405 healthcare providers working in hospitals of Gondar province from November 15, 2020, to March 10, 2021. A simple random sampling technique was employed to select the study subjects. Data were collected via a structured-self-administered questionnaire. EPI INFO version 7.1.2 and SPSS version 25 were used for data entry and analysis respectively. Binary logistic regression analyses were done to identify associated factors and the adjusted odds ratio (AOR) with its 95% confidence interval (CI) at a p-value of <0.05 was used to declare significant association. RESULTS: The healthcare providers' awareness of breastfeeding practice recommendations during the COVID-19 pandemic was 40.7% (95% CI: 35.9, 45.6). Working in a tertiary hospital (AOR = 3.69; 95% CI: 2.24, 6.08), using COVID-19 guideline updates (AOR = 3.34; 95% CI: 2.1, 5.3), being trained on COVID-19 (AOR = 2.78; 95% CI: 1.74, 4.47), owning a smartphone and/or a computer (AOR = 2.26; 95% CI: 1.39, 3.68), and perceiving that COVID-19 is dangerous (AOR = 1.78; 95% CI: 1.05, 3.01) were factors positively associated with healthcare providers' awareness of breastfeeding practice recommendations during the pandemic of COVID-19. CONCLUSION: Only two in five healthcare providers were aware of recommendations on breastfeeding practice during the COVID-19 pandemic and related to information of accessibility information on COVID-19. Therefore, expanding COVID-19 related information through the provision of COVID-19 training and guidelines to all levels of hospitals would improve health care providers' awareness of breastfeeding practice recommendations amid the COVID-19 pandemic.

Lay testing cadres and point-of-care diagnostic tests for HIV and other diseases: An essential combination in health service delivery.

Zibusiso Ndlovu and Tom Ellman discuss the potential value of task sharing in provision of testing for HIV and other infectious diseases.

Reduction of inappropriate prescriptions in older adults through the support of Asynchronous Geriatric Counseling Online (AGAlink): Implemented in primary care.

BACKGROUND/AIM: Medication prescription is a fundamental component in the care of the elderly. Several characteristics of aging and geriatric medicine affect prescriptions for these people and make the selection of drug therapy a difficult and complex process. The objective of this study is to develop a geriatric portal for asynchronous online counseling (AGAlink) for use by physicians specializing in family medicine to reduce medication problems among older adult patients in the first level of care. METHOD: A qualitative study was carried out in the first level of care at the Mexican Institute of Social Security (IMSS), 31 family doctors were interviewed to identify attitudes, preferences about the use of the AGAlink geriatric portal, as well as their recommendations for the implementation of this tool in their daily practice. For the analysis of the data obtained, a qualitative thematic content analysis was used. RESULTS: 90% of the physicians used the geriatric portal outside office hours without the need for the patient to be present. The perception of the physician towards the use of the AGAlink geriatric portal was favorable, provided relevant information and had several positive effects on the process of care for medical prescription. The barriers identified to accept the change in medication were not having the proposed therapeutic option, lack of any laboratory analysis, continuing to consider their experience for the prescription of the medication. CONCLUSIONS: The AGAlink geriatric portal was a tool that was well received by physicians who expressed a positive attitude, considered an investment of a short time that allowed them to update and learn about strategies to reduce the prescription problems presented among the elderly population. However, the main barrier was the use of technology, especially in the doctors with more seniority in the service.

"Sharp downward, blunt upward": district maternal death audits' challenges to formulate evidence-based recommendations in Indonesia - a qualitative study.

BACKGROUND: Indonesia, the largest archipelago globally with a decentralized health system, faces a stagnant high maternal mortality ratio (MMR). The disparity factors among regions and inequities in access have deterred the local assessments in preventing similar maternal deaths. This study explored the challenges of district maternal death audit (MDA) committees to provide evidence-based recommendations for local adaptive practices in reducing maternal mortality. METHODS: A qualitative study was conducted with four focus-group discussions in Central Java, Indonesia, between July and October 2019. Purposive sampling was used to select 7-8 members of each district audit committee. Data were analyzed using the thematic analysis approach. Triangulation was done by member checking, peer debriefing, and reviewing audit documentation. RESULTS: The district audit committees had significant challenges to develop appropriate recommendations and action plans, involving: 1) non-informative audit tool provides unreliable data for review; 2) unstandardized clinical indicators and the practice of "sharp downward, blunt upward"; 3) unaccountable hospital support and lack of leadership commitment, and 4) blaming culture, minimal training, and insufficient MDA committee' skills. The district audit committees tended to associated maternal death in lower and higher-level health facilities (hospitals) with mismanagement and unavoidable cause, respectively. These unfavorable cultures discourage transparency and prevent continuing improvement, leading to failure in addressing maternal death's local avoidable factors. CONCLUSION: A productive MDA is required to provide an evidence-based recommendation. A strong partnership between the key hospital decision-makers and district health officers is needed for quality evidence-based policymaking and adaptive practice to prevent maternal death.

Effectiveness of knowledge brokering and recommendation dissemination for influencing healthcare resource allocation decisions: A cluster randomised controlled implementation trial.

BACKGROUND: Implementing evidence into clinical practice is a key focus of healthcare improvements to reduce unwarranted variation. Dissemination of evidence-based recommendations and knowledge brokering have emerged as potential strategies to achieve evidence implementation by influencing resource allocation decisions. The aim of this study was to determine the effectiveness of these two research implementation strategies to facilitate evidence-informed healthcare management decisions for the provision of inpatient weekend allied health services. METHODS AND FINDINGS: This multicentre, single-blinded (data collection and analysis), three-group parallel cluster randomised controlled trial with concealed allocation was conducted in Australian and New Zealand hospitals between February 2018 and January 2020. Clustering and randomisation took place at the organisation level where weekend allied health staffing decisions were made (e.g., network of hospitals or single hospital). Hospital wards were nested within these decision-making structures. Three conditions were compared over a 12-month period: (1) usual practice waitlist control; (2) dissemination of written evidence-based practice recommendations; and (3) access to a webinar-based knowledge broker in addition to the recommendations. The primary outcome was the alignment of weekend allied health provision with practice recommendations at the cluster and ward levels, addressing the adoption, penetration, and fidelity to the recommendations. The secondary outcome was mean hospital length of stay at the ward level. Outcomes were collected at baseline and 12 months later. A total of 45 clusters (n = 833 wards) were randomised to either control (n = 15), recommendation (n = 16), or knowledge broker (n = 14) conditions. Four (9%) did not provide follow-up data, and no adverse events were recorded. No significant effect was found with either implementation strategy for the primary outcome at the cluster level (recommendation versus control ß 18.11 [95% CI -8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control ß 1.24 [95% CI -6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker ß -9.12 [95% CI -3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control ß 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control ß -0.12 [95% CI -0.54 to 0.30] p = 0.581; recommendation versus knowledge broker ß -0.19 [-1.04 to 0.65] p = 0.651). There was no significant effect between strategies for the secondary outcome at ward level (recommendation versus control ß 2.19 [95% CI -1.36 to 5.74] p = 0.219; knowledge broker versus control ß -0.55 [95% CI -1.16 to 0.06] p = 0.075; recommendation versus knowledge broker ß -3.75 [95% CI -8.33 to 0.82] p = 0.102). None of the control or knowledge broker clusters transitioned to partial or full alignment with the recommendations. Three (20%) of the clusters who only received the written recommendations transitioned from nonalignment to partial alignment. Limitations include underpowering at the cluster level sample due to the grouping of multiple geographically distinct hospitals to avoid contamination. CONCLUSIONS: Owing to a lack of power at the cluster level, this trial was unable to identify a difference between the knowledge broker strategy and dissemination of recommendations compared with usual practice for the promotion of evidence-informed resource allocation to inpatient weekend allied health services. Future research is needed to determine the interactions between different implementation strategies and healthcare contexts when translating evidence into healthcare practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000029291.

Noncompliance with the WHO's Recommended Eight Antenatal Care Visits among Pregnant Women in Sub-Saharan Africa: A Multilevel Analysis.

BACKGROUND: In 2016, the World Health Organization (WHO) introduced a minimum of eight antenatal care (ANC) visits for positive pregnancy outcomes. This study examined the prevalence of noncompliance with 8+ ANCvisits and its associated factors in sub-Saharan Africa (SSA). METHODS: We used data from the Demographic and Health Surveys of eight countries in SSA. A pooled sample of 63,266 pregnant women aged 15-49 years who had given birth to children within 5 years prior to the surveys was included in this study. To examine the factors associated with noncompliance with ANC 8+ visits, multilevel binary logistic regression analysis was conducted, and the results were reported using odds radios at 95% confidence interval (CI). RESULTS: The pooled prevalence of noncompliance with ANC 8+ visits was 92.3% (95% CI: 91.1%-93.3%) with the highest and lowest prevalence in Zambia (98.7%, 95% CI: 98.3%-99.1%) and Libya (73.4%, 95% CI: 70.4%-76.2%), respectively. With the individual level factors, women's age (44-49 years-aOR = 0.33, 9% CI: 0.14-0.78), health insurance registration, (yes-aOR = 0.53, 95% CI: 0.29-0.98), and economic status (richest-aOR = 0.16, 95% CI: 0.05-0.49) were negatively associated with noncompliance with 8+ ANC visits, while parity (five or more children-aOR = 1.68, 95% CI: 1.12-2.52) was positively associated with noncompliance with 8+ ANC visit. With the community level factors, community level literacy was negatively associated with noncompliance with 8+ ANC visit (high-aOR = 0.56, 95% CI: 0.32-0.99). CONCLUSION: About eight out of ten pregnant women did not comply with the WHO's recommended minimum of eight ANC visits for positive pregnancy outcomes in SSA. Empowering the economic status of women , enhancing health insurance and education coverage, and giving more attention to young pregnant women and those with more children are crucial for improving the coverage of ANC 8+ visits in the region.

Impact of the Step-by-Step on febrile infants.

OBJECTIVE: To evaluate the impact of introducing the Step-by-Step approach on care quality in young febrile infants. DESIGN: Observational study including infants ≤90 days old with fever without source seen in a paediatric emergency department 5 years before (n=1222) and after (n=1151) its introduction. Quality of care was evaluated in terms of adherence to recommendations, resource use and safety. RESULTS: Adherence: percentages of infants undergoing both urine and blood tests and infants <15 days old receiving full sepsis evaluation increased (84.7% vs 91.0% and 23.9% vs 63.3%, respectively; p<0.01). Resource use: lumbar puncture and admission rates decreased (24.1% vs 18.7% and 43.6% vs 38.3%, respectively; p<0.01), while the rate of antibiotic therapy increased (30.2% vs 43.2%; p<0.01). SAFETY: the invasive bacterial infection rate among infants managed as outpatients was unchanged (0.7% vs 0.3%; p=0.24). CONCLUSION: The introduction of the Step-by-Step increased the quality of care provided to young febrile infants.