Individually Linked Household and Health Facility Vaccination Survey in 12 At-risk Districts in Kinshasa Province, Democratic Republic of Congo: Methods and Metadata.

Health facility (HF) and household (HH) data can complement each other to provide a better understanding of the factors that contribute to vaccination status. In 12 zones with low vaccination coverage within Kinshasa Province, Democratic Republic of Congo, we conducted 2 surveys: (1) a linked HH and HF survey among 6-11-month-old infants, and (2) a HH survey among 12-23-month-old children. Linked survey objectives were to identify factors associated with vaccination status and to explore methodological considerations for linked survey implementation. To provide linked HH and HF data, we enrolled 6-11-month-old infants in HH clusters in each zone and then surveyed HFs located within the 12 zones and cited by caregivers of the enrolled infants as the most recent HF visited for vaccination or curative care. To provide vaccination coverage estimates for the 12-zone area, we enrolled 12-23-month-old children in every fourth HH. Of the HHs with a child aged 6-23 months, 16% were ineligible because they had resided in the neighborhood for <3 months or were unavailable to be interviewed, 4% refused, and 80% were eligible and participated. Of 1224 enrolled infants 6-11 months of age, records of 879 (72%) were linked to one of the 182 surveyed HFs. For the coverage survey, 710 children aged 12-23 months participated. Home-based vaccination cards were available for 1210 of 1934 children (63%) surveyed. The surveys were successful in assessing HH information for 2 age groups, documenting written vaccination history for a large proportion of 6-23-month-old children, linking the majority of infants with their most recently visited HF, and surveying identified HFs. The implementation of the individually linked survey also highlighted the need for a comprehensive list of HFs and an analysis plan that addresses cross-classified clusters with only 1 child.

Descriptive study of measles vaccination second dose reporting and barriers to improving coverage in six districts in Malawi.

INTRODUCTION: Malawi's National Immunization Program introduced a second routine dose of measles containing vaccine (MCV2) in 2015 but found coverage lagging. We assessed data quality and gaps in service delivery. METHODS: Investigators used a modified data quality audit in 6 low performing districts accompanied by questionnaires for health facilities (HF) and households with children with >1 vaccination. RESULTS: MCV2 doses administered according to source were: 733 in registers, 2364 in reports, 1655 in district reports, 2761 in the electronic database. There was 77% agreement regarding status for MCV2 between the register and the home-based record (HBR). Drop-out differences were found between HF according to the practice of waiting for a minimum number of children to open an MCV vial, canceling sessions due to stock-out and requesting payment for a home-based record. Eighty one percent (81%) of children whose caregivers knew 2 doses were needed had received MCV2 vs fifty eight (58%) of children whose caregivers didn't know. Sixty two (62%) of children who were charged for HBR received MCV2 vs 78% reporting no charge. CONCLUSION: The drop-out between the first and second doses of MCV was high and inconsistent with elimination goals. The quality of administrative data in these 6 districts was found to be poor. This investigation found that session cancelation, charging for HBR and lack of caregiver knowledge affected completion of the vaccination series. The authors recommend program improvements in these areas to increase uptake of MCV2 and improved reporting practices at all levels of the system.

Health Care Worker Preferences and Perspectives on Doses per Container for 2 Lyophilized Vaccines in Senegal, Vietnam, and Zambia.

INTRODUCTION: Limited information exists on health care workers' (HCWs) perceptions about use of multidose vaccine vials and their preferences about doses per container (DPC). We present findings from qualitative studies conducted in Senegal, Vietnam, and Zambia to explore HCWs' behavior regarding opening vials and their perceptions and preferences for the number of doses in vials of BCG and measles-containing vaccine (MCV). Zambia and Senegal currently offer MCV in 10-dose vials and BCG in 20-dose vials; 10-dose vials are used for both vaccines in Vietnam. Unused doses in vials of these reconstituted vaccines must be discarded within 6 hours. METHODS: Key informant interviews (KIIs) were conducted with frontline HCWs in Senegal, Vietnam, and Zambia. In Senegal and Vietnam, the KIIs were conducted as part of broader formative research; in Zambia, KIIs were conducted in control districts using 10-dose MCV vials only and in intervention districts that switched from 10- to 5-dose vials during the study. During analysis, themes common to all 3 countries were synthesized. Critical themes relevant to country contexts were also examined. RESULTS: HCWs in all 3 countries preferred containers with fewer doses for BCG and MCV to reduce wastage and increase the likelihood of vaccinating every eligible child. HCWs in Senegal and HCWs using 10-dose vials in Zambia reported sending unvaccinated children away because not enough children were present to warrant opening a new vial. In Vietnam, where sessions are typically held monthly, and in Zambia when the 5-dose vials were used, almost all HCWs reported opening a vial of MCV for even 1 child. DISCUSSION: HCWs prefer vials with fewer DPC. Their concerns about balancing coverage and wastage influence their decisions to vaccinate every eligible child; and their perspectives are crucial to ensuring that all target populations are reached with vaccines in a timely manner.

A survey of obstetric perianesthesia care unit standards.

BACKGROUND: Although obstetric patients are generally healthy, population risk is increasing because of increases in maternal age, obesity, and rates of multifetal pregnancies, and complications may occur in the immediate postoperative period. In this study, we sought to identify the current level of recovery care for obstetric patients in North American academic institutions after either general or major neuraxial anesthesia for cesarean delivery. METHODS: A survey of obstetric anesthesia recovery practices was delivered electronically to 135 obstetric anesthesiology directors of North American academic institutions from June to October, 2007. Surveys were completed electronically and anonymously. RESULTS: The response rate was 54.8% (74 of 135). Respondents reported a median of 2550 deliveries per year (interquartile range [IQR] 2000, 4000), with 30% delivered by cesarean delivery (IQR 25.5%, 32.5%) and 5% of cesarean deliveries performed under general anesthesia (IQR 4%, 8%). Most institutions recovered postcesarean patients in either an obstetric perianesthesia care unit or a labor, delivery, and recovery room. Recovery care was staffed solely by perinatal nurses, rather than dedicated perianesthesia care unit nurses in most institutions. Forty-five percent (28 of 62) of institutions had no specific postanesthesia recovery training for nursing staff providing postcesarean care for patients recovering from neuraxial or general anesthesia. Forty-three percent (29 of 67) of respondents rated the recovery care provided to cesarean delivery patients as lower quality than care given to general surgical patients. Respondents who relied solely on perinatal nurses to provide postanesthesia care were most likely to perceive that postanesthetic care for cesarean delivery was of lower quality than that given to general surgery patients (P = 0.008). CONCLUSIONS: Guidelines put forth by the American Society of Anesthesiologists Task Force on Postanesthetic Care and the American Society of PeriAnesthesia Nurses apply to all postoperative patients regardless of their recovery locations. Results from this survey suggest that the level of care provided for postanesthesia recovery from cesarean delivery in North American academic institutions may not meet these guidelines.

Propofol Drug Shortage Associated With Worse Postoperative Nausea and Vomiting Outcomes Despite a Mitigation Strategy.

Drug shortages negatively affect patient care and outcomes. Postoperative nausea and vomiting (PONV) can be mitigated using risk assessment and prophylaxis. A 2012 propofol shortage provided an opportunity to study the impact of using prophylactic antiemetics and changing the technique from a propofol infusion to inhaled agents in an ambulatory surgery setting. We retrospectively collected data for 2,090 patients regarding PONV risk factors, anesthetic management, and PONV outcomes for periods before, during, and after the shortage. Patients during the propofol shortage experienced a higher incidence of PONV (11% vs 5% before the shortage), greater need for rescue antiemetics (3% vs 1%), and longer duration of stay (mean [SD] = 124 [115] minutes vs 118 [108] minutes). More patients in this group reported PONV at home (14% vs 7%), and 2 required unplanned admission or return to the hospital. During the shortage, patients had a 2-fold increase in the odds of PONV when adjusted for all risk factors. Antiemetics moderated the association between gender and PONV but did not change the effect of the shortage. Findings suggest that despite mitigation efforts, the inability to use propofol infusion was associated with worse PONV outcomes.

Demonstration of the Use of Remote Temperature Monitoring Devices in Vaccine Refrigerators in Haiti.

After the 2010 earthquake, Haiti committed to introducing 4 new antigens into its routine immunization schedule, which required improving its cold chain (ie, temperature-controlled supply chain) and increasing vaccine storage capacity by installing new refrigerators. We tested the feasibility of using remote temperature monitoring devices (RTMDs) in Haiti in a sample of vaccine refrigerators fueled by solar panels, propane gas, or electricity. We analyzed data from 16 RTMDs monitoring 24 refrigerators in 15 sites from March through August 2014. Although 5 of the 16 RTMDs exhibited intermittent data gaps, we identified typical temperature patterns consistent with refrigerator door opening and closing, propane depletion, thermostat insufficiency, and overstocking. Actual start-up, annual maintenance, and annual electricity costs for using RTMDs were $686, $179, and $9 per refrigerator, respectively. In Haiti, RTMD use was feasible. RTMDs could be prioritized for use with existing refrigerators with high volumes of vaccines and new refrigerators to certify their functionality before use. Vaccine vial monitors could provide additional useful information about cumulative heat exposure and possible vaccine denaturation.

An overview of prion biology and the role of blood filtration in reducing the risk of transfusion-transmitted variant Creutzfeldt-Jakob disease.

Prions are infectious proteins believed to be responsible for a variety of progressive and fatal neurodegenerative diseases, collectively referred to as transmissible spongiform encephalopathies (TSE). By 1996, it was recognized that ingestion of beef from cattle afflicted with a TSE known as bovine spongiform encephalopathy, could result in a devastating human TSE known as variant Creutzfeldt-Jakob disease (vCJD). Two recent reports of probable transfusion-transmitted vCJD have raised concerns about the safety of the blood supply. The relatively long asymptomatic latency of vCJD, as well as the lack of sensitive and specific antemortem tests, increase the risk that asymptomatic, infected individuals may become blood donors. To this point, donor deferral has been a strategy used to reduce this risk. Nevertheless, this strategy may be unreliable and, furthermore, may threaten blood availability. Leukoreduction has also been helpful in reducing cell-associated infectious prion, which has been reported to reduce up to 42% of the infectivity in blood. Proprietary prion affinity surface modifications have been developed and applied to filters, which exploit an understanding of the unique chemical characteristics of prion surfaces. These have been successfully adapted to existing high-efficiency blood filter matrices for the reduction of prions present in blood components for transfusion.

Strengthening capacity in developing countries for evidence-based public health: the data for decision-making project.

Public health officials and the communities they serve need to: identify priority health problems; formulate effective health policies; respond to public health emergencies; select, implement, and evaluate cost-effective interventions to prevent and control disease and injury; and allocate human and financial resources. Despite agreement that rational, data-based decisions will lead to improved health outcomes, many public health decisions appear to be made intuitively or politically. During 1991-1996, the US Centers for Disease Control and Prevention implemented the US Agency for International Development funded Data for Decision-Making (DDM) Project. DDM goals were to: (a) strengthen the capacity of decision makers to identify data needs for solving problems and to interpret and use data appropriately for public health decisions; (b) enhance the capacity of technical advisors to provide valid, essential, and timely data to decision makers clearly and effectively; and (c) strengthen health information systems (HISs) to facilitate the collection, analysis, reporting, presentation, and use of data at local, district, regional, and national levels. Assessments were conducted to identify important health problems, problem-driven implementation plans with data-based solutions as objectives were developed, interdisciplinary, in-service training programs for mid-level policy makers, program managers, and technical advisors in applied epidemiology, management and leadership, communications, economic evaluation, and HISs were designed and implemented, national staff were trained in the refinement of HISs to improve access to essential data from multiple sources, and the effectiveness of the strategy was evaluated. This strategy was tested in Bolivia, Cameroon, Mexico, and the Philippines, where decentralization of health services led to a need to strengthen the capacity of policy makers and health officers at sub-national levels to use information more effectively. Results showed that the DDM strategy improved evidence-based public health. Subsequently, DDM concepts and practices have been institutionalized in participating countries and at CDC.

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.

Detection of bacteria in WBC-reduced PLT concentrates using percent oxygen as a marker for bacteria growth.

BACKGROUND: The risk of receiving a PLT concentrate (PC) contaminated with bacteria may be 1000-fold greater than that of pathogenic viral transmission, yet surveillance for this risk is not generally practiced. A novel bacteria detection system (BDS) that overcomes the limitations of current systems is described. The BDS monitors percent oxygen (%O2) in air above aliquots of PCs that have been filtered to remove the confounding effect of respiring PLTs and residual WBCs. STUDY DESIGN AND METHODS: One-day-old WBC-reduced whole-blood-derived PCs (WBPCs) were inoculated with bacteria at 100 to 500 CFU per mL. After 30 minutes, 2- to 3-mL aliquots were processed through a PLT-reducing filter into a sample pouch containing sodium polyanethol sulfonate and entrained air. After incubation at 35 degrees C for at least 24 hours, the %O2 was measured within the pouch. Noninoculated WBC-reduced WBPCs (n = 155), confirmed free of bacteria by routine culture, were tested in a like manner. Results from the latter group of WBC-reduced WBPCs were used to distinguish contaminated from noncontaminated units. RESULTS: After a 24-hour incubation at 35 degrees C, 195 (96.5%) of the 202 sample pouches obtained from inoculated units were detected by the BDS. After an additional 6 hours at room temperature, those that remained and were tested were found positive. None of the noninoculated controls produced a positive reading. CONCLUSION: The BDS is easy to use and provides good levels of sensitivity and specificity.