Antenatal care utilization and its associated factors in Somalia: a cross-sectional study.

BACKGROUND: WHO recommends attending minimum four ANC consultations during pregnancy to ensure early detection of complications. The objective of this study was to quantify ANC attendance and factors associated with it. METHODS: Participants were randomly selected using the WHO Cluster survey methodology in Southern and Central Somalia. A paper-print questionnaire was used to collect all data. Outcomes of interest were: access to at least one ANC consultation, completion of at least four ANC consultations, initiation of breastfeeding and place of delivery, while exposures included factors related to the latest pregnancy and demographic characteristics. Associations were assessed through logistic regression. RESULTS: Seven hundred ninety-two women answered the questionnaire; 85% attended at least one and 23% at least four ANC consultations, 95% started breastfeeding and 51% had an institutional delivery. Encouragement to attend ANC increased the odds of attending at least one consultation (aOR = 8.22, 95%CI 4.36-15.49), while negative attitude of husband or family decreased the odds (aOR = 0.33, 95%CI 0.16-0.69). Knowing there is a midwife increased the odds of at least four visits (aOR = 1.87, 95%CI 1.03-3.41). Attending at least four consultations increased the odds of delivering in a health structure (aOR = 1.50, 95%CI 1.01-2.24), and attending at least one consultation was associated with higher odds of initiating breastfeeding (aOR = 2.69, 95%CI 1.07-6.74). CONCLUSIONS: Family has a strong influence in women's ANC attendance, which increases the likelihood of institutional delivery and initiating breastfeeding. Women and families need to have access to information about benefits and availability of services; potential solutions can include health education and outreach interventions.

Under-estimation of maternal and perinatal mortality revealed by an enhanced surveillance system: enumerating all births and deaths in Pakistan.

BACKGROUND: Reliable and timely data on maternal and neonatal mortality is required to implement health interventions, monitor progress, and evaluate health programs at national and sub-national levels. In most South Asian countries, including Pakistan, vital civil registration and health information systems are inadequate. The aim of this study is to determine accurate maternal and perinatal mortality through enhanced surveillance of births and deaths, compared with prior routinely collected data. METHODS: An enhanced surveillance system was established that measured maternal, perinatal and neonatal mortality rates through more complete enumeration of births and deaths in a rural district of Pakistan. Data were collected over a period of 1 year (2015/16) from augmentation of the existing health information system covering public healthcare facilities (n = 19), and the community through 273 existing Lady Health Workers; and with the addition of private healthcare facilities (n = 10), and 73 additional Community Health Workers to cover a total study population of 368,454 consisting of 51,690 eligible women aged 18 to 49 years with 7580 pregnancies and 7273 live births over 1 year. Maternal, neonatal, perinatal and stillbirth rates and ratios were calculated, with comparisons to routine reporting from the previous period (2014-15). RESULTS: Higher maternal mortality, perinatal mortality and neonatal mortality rates were observed through enhanced surveillance compared to mortality rates in the previous 1.5 years from the routine monitoring system from increased completeness and coverage. Maternal mortality was 247 compared to 180 per 100, 000 live births (p = 0.36), neonatal mortality 40 compared to 20 per 1, 000 live births (p < 0.001), and perinatal mortality 60 compared to 47 per 1000 live births (p < 0.001). All the mortality rates were higher than provincial and national estimates proffered by international agencies based on successive Pakistan Demographic and Health Surveys and projections. CONCLUSION: Extension of coverage and improvement in completeness through reconciliation of data from health information systems is possible and required to obtain accurate maternal, perinatal and neonatal mortality for assessment of health service interventions at a local level.

Completeness of a Maternal and Perinatal Mortality Enhanced Surveillance System in Pakistan: Evidence from Capture-Recapture Methods.

Objectives An enhanced surveillance system that integrated health information systems and extended surveillance to previously uncovered areas to capture all births, perinatal and maternal deaths in a rural district of Pakistan was established in 2015, and this study uses capture-recapture methodology to assess completeness. Methods Births and deaths collected by the survey were matched with the data captured by the enhanced surveillance system. Capture-recapture methodology was used to estimate the total number of births and deaths, measure the degree of underestimation, and adjust mortality rates. Results Of all births, 99% were captured by the enhanced surveillance system. Ninety percent of neonatal deaths and 86% of early neonatal deaths were recorded. The recorded neonatal mortality rate was 40 per 1000 live births (95% CI 35-44), and after adjustment for under-enumeration was 42 per 1000 live births (95% CI 37-46). Recorded rates underestimated neonatal mortality by 5% and perinatal mortality by 7%. Five stillbirths were recorded by the survey and all were matched to recorded stillbirths. The one maternal death recorded by the survey was matched with the maternal death captured by the enhanced surveillance system. The maternal mortality ratio prior to adjustment for under-enumeration was 247 per 100,000 live births (95% CI 147-391), whereas after adjustment it was 246 per 100,000 live births (95% CI 146-389). Conclusion Application of capture-recapture methods to the enhanced surveillance system indicated a high completeness of birth and death recording by the surveillance system.

Equity and access: understanding emergency health service use by newly arrived refugees.

OBJECTIVES: To determine issues that affect newly resettled refugees in accessing an emergency department (ED). DESIGN, SETTING AND PARTICIPANTS: We conducted a descriptive community survey using a semistructured questionnaire. Newly resettled refugees from the Middle East and Africa were interviewed, statistical analysis was performed, and standard content analysis methods were applied to free-text responses. MAIN OUTCOME MEASURES: Emergency health-seeking behaviour, sociocultural barriers and beliefs about Australia's emergency health services. RESULTS: Half the African refugees (53/106) (50%), compared with only 15/49 (31%) of the Middle Eastern refugees, preferred an ED service over other forms of care for an urgent medical condition (P = 0.024). Qualitative data revealed that most newly resettled refugees understand how to use the emergency health services. However, while most indicated that they were able to make a call for emergency medical help, a substantial number of our respondents revealed that they were afraid to make such a call for fear of security implications, on the basis of experiences from their home countries. CONCLUSION: Reasons for differences in preferences of health care access, and determining how best to educate the community on the use of ED services, warrant further investigation. From a policy perspective, the increasing health care needs of refugees need re-examination when planning health care provision to refugees.

The epidemiology of health conditions of newly arrived refugee children: a review of patients attending a specialist health clinic in Sydney.

AIM: To determine the prevalence of common diseases in newly arrived refugee children, resettled in Sydney, by region of birth. To identify health needs of refugee children in Australia. METHODS: We prospectively screened for common diseases in refugee children attending a specialist paediatric refugee clinic, the Children's Hospital, Westmead, between May 2005 and December 2006. Screening tests included full blood count, Mantoux, vitamin D level, hepatitis B serology, syphilis serology, Schistosomiasis serology and malarial antigens. RESULTS: There were 239 patients, the majority (75%) from Africa, with 127 girls and 112 boys. Thirty-six percent were 0-7 years old, 45% were 8-12 years old and 19% were 13-17 years old. Of those tested, 16% had Schistosomiasis, 5% had malaria and 4% were hepatitis B carriers. Of 216 children who had Mantoux tests, 33% were > or =10 mm and 24% were > or =15 mm, including four children with active disease (2 lymphadenitis, 1 pulmonary and 1 gastric). Vitamin D deficiency was the most common diagnosis: 61% had serum 25(OH)D3 <50 nmol/L. Anaemia was present in 15%. Disease prevalence was higher in children from Africa than Asia or the Middle East, and most of the children were asymptomatic. Given that we have only seen about 10% of the refugee children resettled in New South Wales, our results may not be generalisable to all refugees. CONCLUSION: Our findings suggest that screening refugee children for common treatable conditions, even if they are asymptomatic, is paramount. In addition to infectious diseases screening, nutritional deficiencies should routinely be screened for.

The impact of intensive health promotion to a targeted refugee population on utilisation of a new refugee paediatric clinic at the children's hospital at Westmead.

OBJECTIVE: To evaluate the impact of intensive promotion of a new health service to a targeted refugee population, recently resettled in Sydney, and the role of early social connection and membership of social group in promoting health service utilisation of refugees. DESIGN: Descriptive epidemiological study and survey. SETTINGS: A paediatric refugee clinic at a children's hospital in Sydney. PARTICIPANTS: Newly resettled refugee parents of children seen at the clinic. INTERVENTIONS: An intensive health promotion and education campaign using ethnic media and social networks to increase awareness of and encourage utilisation of a new clinical service for refugee children (above and beyond the standard promotion that accompanied the start of the new refugee clinic) to a targeted group of refugees from Sub-Saharan Africa. MAIN OUTCOME MEASURE(S): Rates of attendance and utilisation of the new service in targeted versus non-targeted refugee parents; changes in health beliefs, health-seeking behaviour and utilisation of services following clinic attendance. RESULTS: We interviewed 34 Sub-Saharan African refugee parents (intervention) and 12 non-African refugee parents (non-intervention) attending a paediatric refugee clinic, between June 2005 and May 2006, with a total number of 112 children. The mean ages of the children were 12 and 10 years for the Africans and non-Africans, respectively. Our targeted health promotion campaign appeared to be effective in increasing attendance for target communities compared to the non-targeted communities (OR for African families attending clinic 3.0, 95% CI=1.5-6.2, p<0.001). We observed a significant change in parental knowledge, attitudes and beliefs about infectious diseases after attending the clinic, including decreased stigma around tuberculosis, more awareness of the seriousness of some infections, and increased awareness of the role of immunisation in prevention of infectious diseases. CONCLUSION: Our study shows that targeted promotion of service to refugee parents is effective. Such efforts may improve access to care for refugees and may constructively change knowledge, attitudes and beliefs about infectious diseases.

Recent advances in the development of monoclonal antibodies for rabies post exposure prophylaxis: A review of the current status of the clinical development pipeline.

Despite successful control in many parts of the world, rabies virus continues to result in tens of thousands of deaths each year. Death from rabies can be prevented by timely and appropriate post exposure prophylaxis including wound cleaning and administration of vaccine and rabies immunoglobulin. Currently, rabies immunoglobulin is derived from the blood plasma of horses or humans and has several limitations relating to supply, cost and quality. Monoclonal antibodies produced through recombinant DNA technologies could potentially overcome these limitations. The first anti-rabies monoclonal antibody has recently gained regulatory approval in India and there are several other candidates being evaluated in clinical trials. Given the advances in the field, rabies monoclonal antibodies have been recently considered by the World Health Organization's Strategic Advisory Group of Experts on Immunization and included in updated WHO immunization policy recommendations for rabies published in April 2018. This article reviews the current landscape of the clinical trial development of anti-rabies monoclonal antibodies and the historical clinical trial pathways followed for blood-derived rabies immunoglobulin before discussing challenges in the clinical evaluation, regulatory approval, uptake and monitoring of these products.

Adherence to anti-vectorial prevention measures among travellers with chikungunya and malaria returning to Australia: comparative epidemiology.

OBJECTIVE: Compare the adoption and adherence to health protection behaviours prior to and during travel among international Australian travellers who return to Australia with notified chikungunya or malaria infection. This information could inform targeted health promotion and intervention strategies to limit the establishment of these diseases within Australia. RESULTS: Seeking travel advice prior to departure was moderate (46%, N = 21/46) yet compliance with a range of recommended anti-vectorial prevention measures was low among both chikungunya and malaria infected groups (16%, N = 7/45). Reasons for not seeking advice between groups was similar and included 'previous overseas travel with no problems' (45%, N = 9/20) and 'no perceived risk of disease' (20%, N = 4/20). Most chikungunya cases (65%, N = 13/20) travelled to Indonesia and a further 25% (N = 5/20) visited India, however most malaria cases (62%, N = 16/26) travelled to continental Africa with only 12% (N = 3/26) travelling to India. The majority (50%, N = 10/20) of chikungunya cases reported 'holiday' as their primary purpose of travel, compared to malaria cases who most frequently reported travel to visit friends and family (VFR; 42%, N = 11/26). These results provide import data that may be used to support distinct public health promotion and intervention strategies of two important vector-borne infectious diseases of concern for Australia.

Risk activities and pre-travel health seeking practices of notified cases of imported infectious diseases in Australia.

BACKGROUND: Travellers are at risk of acquiring infectious diseases during travel, with risks differing by destination, travel and traveller characteristics. A pre-travel health consultation may minimize this risk. However, uptake of pre-travel health advice remains low. We investigated pre-travel health preparations and disease-specific risk behaviours among notified cases of selected travel-associated infectious diseases imported into Australia. METHODS: Prospective enhanced surveillance of notified cases of typhoid, paratyphoid, measles, hepatitis A, hepatitis E, malaria and chikungunya was conducted in two Australian states between February 2013 and January 2014. Details of pre-travel health preparation and disease-specific risk behaviours were collected. RESULTS: Among 180 cases associated with international travel, 28% were <18 years, 65% were VFR travellers and 22% were frequent travellers, having travelled ≥5 times in the past 5 years. 25% had sought pre-travel advice from a healthcare provider, and 16% reported a pre-travel vaccine. Seeking pre-travel health advice did not differ by immigrant status ( P = 0.22) or by reason for travel ( P = 0.13) but was more commonly sought by first time travellers ( P = 0.03). Travellers visiting friends and relatives were more likely to report at-risk activities of brushing teeth with tap water ( P < 0.001) and eating uncooked food ( P = 0.03) during travel compared to other travellers. CONCLUSIONS: Pre-travel health advice seeking practices and vaccine uptake was suboptimal among cases of notified disease. The results of this study highlight the need for a better understanding of barriers to pre-travel health seeking, particularly among high risk travellers, to reduce the importation of infectious diseases into Australia.

Does Zika Virus Cause Microcephaly - Applying the Bradford Hill Viewpoints.

INTRODUCTION: Zika virus has been documented since 1952, but been associated with mild, self-limiting disease. Zika virus is classified as an arbovirus from a family of Flaviviridae and primarily spread by Aedes Aegypti mosquitos. However, in a large outbreak in Brazil in 2015, Zika virus has been associated with microcephaly. METHODS: In this review we applied the Bradford-Hill viewpoints  to investigate the association between Zika virus and microcephaly. We examined historical studies, available data and also compared historical rates of microcephaly prior to the Zika virus outbreak. The available evidence was reviewed against the Bradford Hill viewpoints. RESULTS: All  the nine criteria were met to varying degrees: strength of association, consistency of the association, specificity, temporality, plausibility, coherence, experimental evidence, biological gradient and analogy. Conclusion: Using the Bradford Hill Viewpoints as an evaluation framework for causation is highly suggestive that the association between Zika virus and microcephaly is causal. Further studies using animal models on the viewpoints which were not as strongly fulfilled would be helpful.

Passive immunization for influenza through antibody therapies, a review of the pipeline, challenges and potential applications.

The Global Action Plan for influenza vaccines (GAP) aims to increase the production capacity of vaccines so that in the event of a pandemic there is an adequate supply to meet global needs. However, it has been estimated that even in the best case scenario there would be a considerable delay of at least five to six months for the first supplies of vaccine to become available after the isolation of the strain and availability of the candidate vaccine virus to vaccine manufacturers. By this time, the virus is likely to have already infected millions of people worldwide, causing significant mortality, morbidity and economic loss. Passive immunization through broadly neutralizing antibodies which bind to multiple, structurally diverse strains of influenza could be a promising solution to address the immediate health threat of an influenza pandemic while vaccines are being developed. These products may also have a role in seasonal influenza as an alternative to other options such as antivirals for the treatment of severe acute respiratory illness due to influenza. This article provides an overview of the current clinical pipeline of anti-influenza antibodies and discusses potential uses and the challenges to product development.

Australian Hajj pilgrims' infection control beliefs and practices: Insight with implications for public health approaches.

BACKGROUND: Hajj is one of the largest annual mass gatherings around the world. Although the Saudi Arabian health authority recommends vaccination and other infection control measures, studies identified variable uptake of these measures among pilgrims, and the reasons behind this variability remain unclear. This qualitative study aimed to addresses this knowledge gap. METHODS: In-depth interviews were conducted with pilgrims over 18 years of age. RESULTS: A total of 10 participants took part in the study. There was low perception of the potential severity of respiratory conditions and the need for influenza vaccination during Hajj. Different attitudes were found by age group with elderly participants believing that they were under Allah's protection, and were fatalistic about the risk of illness. While younger participants described the impact infections would have on their worship. Facemask use was infrequent with discomfort; difficulty in breathing and a feeling of isolation were commonly cited barriers to use of facemasks. Participants accepted and trusted preventative health advice from travel agents and friends who had previously undertaken the Hajj more so than primary care practitioners. CONCLUSIONS: This study extended our understanding of how health beliefs influence uptake of preventive measures during the Hajj, and the gaps in the provision of Hajj-specific health information to pilgrims.

Vitamin D deficiency in refugee children from conflict zones.

Vitamin D deficiency is common in newly resettled refugee children and is associated with significant morbidity including rickets. To determine risk factors and burden of vitamin D deficiency in newly resettled refugee children in Australia. A descriptive epidemiological study and survey on refugee children attending an outpatient general health clinic at the Children's Hospital Westmead, Sydney. 215 patients were examined (age range 0-17 years), (76%) majority were from Africa. Mean serum 25OHD level was 46 nmol/L (SD = 24) (sufficiency range 50-150 nmol/L). 40% had mild deficiency (26-50 nmol/L), 19% moderate deficiency (13-25 nmol/L) and 2% were severely deficient (<13 nmol/L). Deficiency was most common in East African (72%) and Middle Eastern (66%) refugees, children in early puberty (89%) and those living in Australia >6 months (71%). Deficient children were more likely to have had movement restrictions and longer time in hiding in their country of refuge (OR 3:1[CI 0.9-9.7], P = .062).

Management of old world cutaneous leishmaniasis in refugee children.

The optimal treatment of cutaneous leishmaniasis is controversial. We report our experience managing Old World cutaneous leishmaniasis in a pediatric refugee clinic. Conventional amphotericin B therapy caused reversible renal failure in 2 of 3 children treated. The choice of treatment for cutaneous leishmaniasis needs to balance the risks of treatment against the likely cosmetic benefits of therapy.