Medical Costs of Respiratory Syncytial Virus-Associated Hospitalizations and Emergency Department Visits in Children Aged Younger Than 5 Years: Observational Findings from the New Vaccine Surveillance Network, 2016-2019.

OBJECTIVE: To assess medical costs of hospitalizations and emergency department (ED) care associated with respiratory syncytial virus (RSV) disease in children enrolled in the New Vaccine Surveillance Network. STUDY DESIGN: We used accounting and prospective surveillance data from 6 pediatric health systems to assess direct medical costs from laboratory-confirmed RSV-associated hospitalizations (n = 2007) and ED visits (n = 1267) from 2016 through 2019 among children aged <5 years. We grouped costs into categories relevant to clinical care and administrative billing practices. We examined RSV-associated medical costs by care setting using descriptive and bivariate analyses. We assessed associations between known RSV risk factors and hospitalization costs and length of stay using χ2 tests of association. RESULTS: The median cost was $7100 (IQR $4006-$13 355) per hospitalized child and $503 (IQR $387-$930) per ED visit. Eighty percent (n = 2628) of our final sample were children aged younger than 2 years. Fewer weeks' gestational age was associated with greater median costs in hospitalized children (P < .001, ≥37 weeks of gestational age: $6840 [$3905-$12 450]; 29-36 weeks of gestational age: $7721 [$4362-$15 274]; <29 weeks of gestational age: $9131 [$4518-$19 924]). Infants born full term accounted for 70% of the total expenditures in our sample. Almost three quarters of the health care dollars spent originated in children younger than 12 months of age, the primary age group targeted by recommended RSV prophylactics. CONCLUSIONS: Reducing the cost burden for RSV-associated medical care in young children will require prevention of RSV in all young children, not just high-risk infants. Newly available maternal vaccine and immunoprophylaxis products could substantially reduce RSV-associated medical costs.

Equity throughout the life course and the evolving role of the Pan American Health Organization.

The objective of this article is to summarize the evolution of the regional commitments of the Pan American Health Organization (PAHO) on health promotion and strategies to improve the health and well-being of women, children, adolescents, and older persons. PAHO regional strategies approved by Member States in the last 20 years are used as the main source of information. The article presents the challenges of making health promotion a public health strategy widely applied in the Region of the Americas and the efforts to renew Member States' collective actions. The article also describes current PAHO efforts to include the positive aspects of health (i.e., well-being, optimal development, and functional ability) and the life course approach as opportunities to advance equity. The article reflects on immunization as a public good and the urgency to address the current challenges as a core element of the regional efforts to transform health systems after more than two years of the COVID-19 pandemic.

El objetivo de este artículo es resumir la evolución de los compromisos regionales de la Organización Panamericana de la Salud (OPS) en materia de promoción de la salud y estrategias para mejorar la salud y el bienestar de mujeres, niños y niñas, adolescentes y personas mayores. Se han empleado como principal fuente de información las estrategias regionales de la OPS aprobadas por los Estados Miembros en los últimos 20 años. En el artículo se presentan los desafíos de convertir la promoción de la salud en una estrategia de salud pública de amplia ejecución en la Región de las Américas y los esfuerzos para renovar las medidas colectivas de los Estados Miembros. Asimismo, se describe la labor actual de la OPS para incluir los aspectos positivos de la salud (como el bienestar, el desarrollo óptimo y la capacidad funcional) y el enfoque del curso de vida como oportunidades para fomentar la equidad. Finalmente, se reflexiona sobre la inmunización como bien público y la urgencia de abordar los desafíos actuales como elemento central de los esfuerzos regionales para transformar los sistemas de salud tras más de dos años de pandemia de COVID-19.

O objetivo deste artigo é resumir a evolução dos compromissos regionais da Organização Pan-Americana da Saúde (OPAS) relativos à promoção da saúde e estratégias para melhorar a saúde e o bem-estar de mulheres, crianças, adolescentes e pessoas idosas. As estratégias regionais da OPAS aprovadas pelos Estados Membros nos últimos 20 anos são a principal fonte de informação. O artigo apresenta os desafios enfrentados para fazer da promoção da saúde uma estratégia de saúde pública amplamente aplicada na Região das Américas e os esforços para renovar as ações coletivas dos Estados Membros. O artigo também descreve os atuais esforços da OPAS para incluir os aspectos positivos da saúde (isto é, bem-estar, desenvolvimento ideal e habilidade funcional) e a abordagem de curso da vida como oportunidades para promover a equidade. O artigo faz reflexões sobre a imunização como um bem público e a urgência de abordar os desafios atuais como um elemento central dos esforços regionais para transformar os sistemas de saúde após mais de dois anos da pandemia de COVID-19.

Equity throughout the life course and the evolving role of the Pan American Health Organization / Equidad a lo largo del curso de vida y la evolución del papel de la Organización Panamericana de la Salud / Equidade ao longo da vida e a evolução do papel da Organização Pan-Americana da Saúde

ABSTRACT The objective of this article is to summarize the evolution of the regional commitments of the Pan American Health Organization (PAHO) on health promotion and strategies to improve the health and well-being of women, children, adolescents, and older persons. PAHO regional strategies approved by Member States in the last 20 years are used as the main source of information. The article presents the challenges of making health promotion a public health strategy widely applied in the Region of the Americas and the efforts to renew Member States' collective actions. The article also describes current PAHO efforts to include the positive aspects of health (i.e., well-being, optimal development, and functional ability) and the life course approach as opportunities to advance equity. The article reflects on immunization as a public good and the urgency to address the current challenges as a core element of the regional efforts to transform health systems after more than two years of the COVID-19 pandemic.

RESUMEN El objetivo de este artículo es resumir la evolución de los compromisos regionales de la Organización Panamericana de la Salud (OPS) en materia de promoción de la salud y estrategias para mejorar la salud y el bienestar de mujeres, niños y niñas, adolescentes y personas mayores. Se han empleado como principal fuente de información las estrategias regionales de la OPS aprobadas por los Estados Miembros en los últimos 20 años. En el artículo se presentan los desafíos de convertir la promoción de la salud en una estrategia de salud pública de amplia ejecución en la Región de las Américas y los esfuerzos para renovar las medidas colectivas de los Estados Miembros. Asimismo, se describe la labor actual de la OPS para incluir los aspectos positivos de la salud (como el bienestar, el desarrollo óptimo y la capacidad funcional) y el enfoque del curso de vida como oportunidades para fomentar la equidad. Finalmente, se reflexiona sobre la inmunización como bien público y la urgencia de abordar los desafíos actuales como elemento central de los esfuerzos regionales para transformar los sistemas de salud tras más de dos años de pandemia de COVID-19.

RESUMO O objetivo deste artigo é resumir a evolução dos compromissos regionais da Organização Pan-Americana da Saúde (OPAS) relativos à promoção da saúde e estratégias para melhorar a saúde e o bem-estar de mulheres, crianças, adolescentes e pessoas idosas. As estratégias regionais da OPAS aprovadas pelos Estados Membros nos últimos 20 anos são a principal fonte de informação. O artigo apresenta os desafios enfrentados para fazer da promoção da saúde uma estratégia de saúde pública amplamente aplicada na Região das Américas e os esforços para renovar as ações coletivas dos Estados Membros. O artigo também descreve os atuais esforços da OPAS para incluir os aspectos positivos da saúde (isto é, bem-estar, desenvolvimento ideal e habilidade funcional) e a abordagem de curso da vida como oportunidades para promover a equidade. O artigo faz reflexões sobre a imunização como um bem público e a urgência de abordar os desafios atuais como um elemento central dos esforços regionais para transformar os sistemas de saúde após mais de dois anos da pandemia de COVID-19.

Glucose-6-phosphate dehydrogenase deficiency in internationally adopted children.

There are conflicting guidelines about screening of internationally adopted children for glucose-6-phosphate dehydrogenase (G6PD) deficiency, a common genetic disorder. In a multi-ethnic population of 2,169 internationally adopted children, we found that the prevalence of G6PD deficiency was 1.6% overall and 2.2% in males. Prevalence differed by country or region of origin, ranging from 0 to 13% overall and 0 to 22% in males. The prevalence in females was 1%. A diagnosis of G6PD deficiency informs the treatment of malaria and enables education and counseling to prevent morbidity and mortality from G6PD deficiency. Screening for G6PD deficiency should be strongly considered for internationally adopted children.

Enterovirus D68 Infection Among Children With Medically Attended Acute Respiratory Illness, Cincinnati, Ohio, July-October 2014.

BACKGROUND: Enterovirus D68 (EV-D68) caused a widespread outbreak of respiratory illness in the United States in 2014, predominantly affecting children. We describe EV-D68 rates, spectrum of illness, and risk factors from prospective, population-based acute respiratory illness (ARI) surveillance at a large US pediatric hospital. METHODS: Children <13 years of age with ARI and residence in Hamilton County, Ohio were enrolled from the inpatient and emergency department (ED) settings at a children's hospital in Cincinnati, Ohio, from 1 July to 31 October 2014. For each participant, we interviewed parents, reviewed medical records, and tested nasal and throat swabs for EV-D68 using real-time reverse- transcription polymerase chain reaction assay. RESULTS: EV-D68 infection was detected in 51 of 207 (25%) inpatients and 58 of 505 (11%) ED patients. Rates of EV-D68 hospitalization and ED visit were 1.3 (95% confidence interval [CI], 1.0-1.6) and 8.4 per 1000 children <13 years of age, respectively. Preexisting asthma was associated with EV-D68 infection (adjusted odds ratio, 3.2; 95% CI, 2.0-5.1). Compared with other ARI, children with EV-D68 were more likely to be admitted from the ED (P ≤ .001), receive supplemental oxygen (P = .001), and require intensive care unit admission (P = .04); however, mechanical ventilation was uncommon (2/51 inpatients; P = .64), and no deaths occurred. CONCLUSIONS: During the 2014 EV-D68 epidemic, high rates of pediatric hospitalizations and ED visits were observed. Children with asthma were at increased risk for medically attended EV-D68 illness. Preparedness planning for a high-activity EV-D68 season in the United States should take into account increased healthcare utilization, particularly among children with asthma, during the late summer and early fall.

Equity, sustainability and governance in urban settings.

In this commentary the urban setting is explored from the perspective of ecological sustainability and social equity. Urban-related issues are highlighted related to social inequality, deficits in urban infrastructures, behavior-related illnesses and risks, global ecological changes, and urban sprawl. Approaches to addressing these issues are described from the perspective of urban governance, urban planning and design, social determinants of health, health promotion, and personal and community empowerment. Examples of successful strategies are provided from Latin America, including using participatory instruments (assessments, evaluation, participatory budgeting, etc.), establishing intersectoral committees, increasing participation of civil society organizations, and developing virtual forums and networks to channel participatory and collaborative processes. A way forward is proposed, using the urban setting to show the imperative of creating intersectoral policies and programs that produce environments that are both healthy and sustainable. It will be important to include new forms of social participation and use social media to facilitate citizen decision-making and active participation of all sectors of society, especially excluded groups.

Rotavirus-associated hospitalization and emergency department costs and rotavirus vaccine program impact.

OBJECTIVES: To determine the medical costs of laboratory-confirmed rotavirus hospitalizations and emergency department (ED) visits and estimate the economic impact of the rotavirus vaccine program. PATIENTS AND METHODS: During 4 rotavirus seasons (2006-2009), children <3 years of age hospitalized or seen in the ED with laboratory-confirmed rotavirus were identified through active population-based rotavirus surveillance in three US counties. Medical costs were obtained from hospital and physician billing data, and factors associated with increased costs were examined. Annual national costs were estimated using rotavirus hospitalization and ED visit rates and medical costs for rotavirus hospitalizations and ED visits from our surveillance program for pre- (2006-2007) and post-vaccine (2008-2009) time periods. RESULTS: Pre-vaccine, for hospitalizations, the median medical cost per child was $3581, the rotavirus hospitalization rate was 22.1/10,000, with an estimated annual national cost of $91 million. Post-vaccine, the median medical cost was $4304, the hospitalization rate was 6.3/10,000 and the estimated annual national cost was $31 million. Increased costs were associated with study site, age <3 months, underlying medical conditions and an atypical acute gastroenteritis presentation. For ED visits, the pre-vaccine median medical cost per child was $574, the ED visit rate was 291/10,000 resulting in an estimated annual national cost of $192 million. Post-vaccine, the median medical cost was $794, the ED visit rate was 71/10,000 with an estimated annual national cost of $65 million. CONCLUSIONS: After implementation of rotavirus immunization, the total annual medical costs decreased from $283 million to $96 million, an annual reduction of $187 million.

Infectious complications of intrathecal baclofen pump devices in a pediatric population.

BACKGROUND: Intrathecal baclofen (ITB) is an effective therapy for spasticity and dystonia in pediatric populations; however, there are associated infectious complications. METHODS: Patients who had an initial ITB device implanted at our center were followed to determine the proportion of patients with infectious and noninfectious complications, identify risk factors for infection and describe the clinical presentations, treatment and outcomes of infectious complications. RESULTS: Over the 15-year study period, 139 patients had an initial ITB device placed. The mean age at placement was 13.6 years (range: 6 months to 41 years). In the first year of follow-up, 83% had no complications or secondary procedures, 17% had at least 1 secondary procedure and 5% had an infectious complication. The median time until infection was 14 days (mean 33 ± 42 days). Patients with secondary spasticity or dystonia were more likely to have infections than patients with cerebral palsy (86% versus 14%; P < 0.0001). In the 94 patients with a first secondary procedure, 29% had at least 1 other procedure and 8% had an infection in the 1 year follow-up. Overall, 24 patients had 27 infections; 22% superficial, 33% deep and 45% organ space. Staphylococcus aureus was isolated in 50% of those with cultures obtained. Explantation was required in 59% of patients with an infection and differed by infection type: superficial (17%), deep (44%) and organ space (92%) (P = 0.004). CONCLUSIONS: Infectious complications were relatively uncommon; however, when present, frequently led to the explantation of the ITB pump device.

Effective global health promotion achievements, tools, and strategies used in the Americas over the past decade.

There have been numerous international commitments made by governments from around the world to promote health and prevent illness and disease. As globalization increases our interdependence with both positive and negative effects, the World Health Organization and the Pan American Health Organization (its Regional Office for the Americas), have responded to ever increasing mandates from their member countries by developing responses to support governments in promoting health and incorporating upstream approaches into their policies, programs and activities. This article highlights some of the most important of these political declarations that have direct impact on health education and promotion ranging from the Alma Ata Declaration on Primary Health Care in 1978 to the Rio Declaration on the Social Determinants of Health in 2011. Additionally, emphasis is placed on identifying and providing examples of the application of specific tools, strategies and approaches to facilitate fulfillment of these mandates; ones that should be useful for health education and promotion practitioners everywhere. It closes by raising some of the challenges that health education and promotion will face in the future given the current trends in the world today.

2009 pandemic influenza A (H1N1) in critically ill children in Cincinnati, Ohio.

OBJECTIVE: To compare the clinical features, management, and outcome of critically ill children with H1N1 to children with seasonal influenza from the previous three influenza seasons. DESIGN: The overall number of hospitalizations and the proportion cared for in the pediatric intensive care unit during the H1N1 epidemic period and the three previous influenza seasons (2007-2009) were determined. Medical records of patients admitted to the pediatric intensive care unit with H1N1 and seasonal influenza infection were reviewed. SETTING: Cincinnati Children's Hospital Medical Center, a large, 523-bed hospital located in Cincinnati. PATIENTS: Hospitalized children with laboratory-confirmed seasonal or H1N1 infection. MEASUREMENTS: Study variables included demographic data (age, gender), clinical factors (weight, Pediatric Risk of Mortality III scores, presenting signs and symptoms, comorbid conditions), management (length of mechanical ventilation, other treatments, including high-frequency oscillatory ventilatory support, inhaled nitric oxide, or extracorporeal membrane oxygenation), and outcome (overall and pediatric intensive care unit length of stay and mortality). MAIN RESULTS: Overall, 312 children were hospitalized with H1N1 and 222 with seasonal influenza from the three previous seasons. Children with H1N1 infection were significantly less likely to require pediatric intensive care unit care compared to children with seasonal influenza infection (14% vs. 24%, p = .02). Compared to children with seasonal influenza, children in the pediatric intensive care unit with H1N1 were older (median age in months 107 vs. 68, p = .05) and significantly more likely to have comorbid conditions (64% vs. 40%, p = .03), especially respiratory conditions. While there were no significant differences in severity of illness by Pediatric Risk of Mortality III scores or pediatric intensive care unit length of stay, children with H1N1 were significantly less likely to have acute respiratory failure (p = .04) or die compared to children with seasonal influenza infection (p = .03). CONCLUSIONS: In contrast to other studies, we found that critically ill children with H1N1 had a significantly lower morbidity and mortality compared to children with seasonal influenza.

Rights, knowledge, and governance for improved health equity in urban settings.

All three of the interacting aspects of daily urban life (physical environment, social conditions, and the added pressure of climate change) that affect health inequities are nested within the concept of urban governance, which has the task of understanding and managing the interactions among these different factors so that all three can be improved together and coherently. Governance is defined as: "the process of collective decision making and processes by which decisions are implemented or not implemented": it is concerned with the distribution, exercise, and consequences of power. Although there appears to be general agreement that the quality of governance is important for development, much less agreement appears to exist on what the concept really implies and how it should be used. Our review of the literature confirmed significant variation in meaning as well as in the practice of urban governance arrangements. The review found that the linkage between governance practices and health equity is under-researched and/or has been neglected. Reconnecting the fields of urban planning, social sciences, and public health are essential "not only for improving local governance, but also for understanding and addressing global political change" for enhanced urban health equity. Social mobilization, empowering governance, and improved knowledge for sustainable and equitable development in urban settings is urgently needed. A set of strategic research questions are suggested.

Igualdad y equidad: pasos necesarios para construir una universidad más saludable / Equality and equity: necessary steps to build a healthier university

El concepto de promoción de la salud surgió de forma simultánea al de igualdad y equidad. Estos conceptos implicaron un giro en la forma de explicar fenómenos de salud-enfermedad, incorporando la perspectiva psicosocial y contextual. No se ha desarrollado una reflexión crítica sobre cómo una universidad saludable debe incorporar la perspectiva de igualdad y equidad en salud. OBJETIVOS: describir la relación entre estos conceptos; identificar mecanismos explicativos de desigualdad; proponer pasos a seguir para promover la equidad e igualdad en una universidad. METODOLOGIA: búsqueda de literatura en bases de datos y reportes recomendados por expertos. Resultados: se presentan definiciones de determinantes sociales de salud, desigualdad, equidad y promoción de salud; se revisa la evidencia de desigualdad social y sus consecuencias en salud en la comunidad universitaria; se discuten posibles modelos explicativos de dichas desigualdades y se establecen algunos posibles pasos a seguir para reducir estas diferencias en salud en una universidad. CONCLUSIONES: un ambiente universitario más igualitario y equitativo podría contribuir de manera concreta a catalizar una vida sana en esta comunidad. Una universidad con estructura y cultura más igualitaria y equitativa, es un camino desafiante y complejo, pero seguro hacia el éxito.

The concept of health promotion emerged simultaneously with those of equality and equity. These concepts implied a change in the way in which the phenomena known as health and disease are explained, thus incorporating psychosocial and contextual perspectives. However, no critical reflection has been developed regarding how a healthy university should incorporate the perspectives of equality and equity in terms of health. OBJECTIVES: to describe the relationship between these concepts, identify the mechanisms that explain inequality, and propose steps to promote equity and equality at the university level. METHODOLOGY: a literature search using databases and reports recommended by experts (a total of 62 documents.). RESULTS: we present definitions for the social determinants of health, equality, equity, and health promotion. We also review the evidence of social inequality and its impact on health in the university community. Likewise we discuss possible models explaining these inequalities and establish some possible steps to follow in order to reduce the differences in terms of health at the university level. CONCLUSIONS: a more equal and equitable university environment could contribute specifically to bring about a healthy life in its community. Achieving a university with a more egalitarian and equitable structure and culture is a challenging and complex task, but it will surely lead to success.

Intestinal parasite screening in internationally adopted children: importance of multiple stool specimens.

OBJECTIVE: Our goal was to determine the prevalence of intestinal parasites in internationally adopted children, to examine factors associated with infection, and to determine if evaluating multiple stool specimens increases the yield of parasite identification. METHODS: We evaluated internationally adopted children with at least 1 stool specimen submitted for ova and parasite testing within 120 days after arrival to the United States. In children submitting 3 stool specimens, in which at least 1 specimen was positive for the pathogen studied, we examined whether multiple stool specimens increased the likelihood of pathogen identification. RESULTS: Of the 1042 children studied, 27% had at least 1 pathogen identified; with pathogen-specific prevalence of Giardia intestinalis (19%), Blastocystis hominis (10%), Dientamoeba fragilis (5%), Entamoeba histolytica (1%), Ascaris lumbricoides (1%), and Hymenolepsis species (1%). The lowest prevalence occurred in South Korean (0%), Guatemalan (9%), and Chinese (13%) children, and the highest prevalence occurred in Ethiopian (55%) and Ukrainian (74%) children. Increasing age was significantly associated with parasite identification, whereas malnutrition and gastrointestinal symptoms were not. Overall, the yield of 1 stool specimen was 79% with pathogen recovery significantly increasing for 2 (92%) and 3 (100%) specimens, respectively (P < .0001). Pathogen identification also significantly increased with evaluation of additional stool specimens for children with and without gastrointestinal symptoms. CONCLUSIONS: We provide data for evidence-based guidelines for intestinal parasite screening in internationally adopted children. Gastrointestinal symptoms were not predictive of pathogen recovery, and multiple stool specimens increased pathogen identification in this high-risk group of children.

Estimating the rotavirus hospitalization disease burden and trends, using capture-recapture methods.

BACKGROUND: Rotavirus surveillance is needed to provide estimates of disease burden and to evaluate the effect of vaccination programs. Our objective was to use capture-recapture methods to estimate rotavirus hospitalization rates and to examine trends over time. METHODS: Children <3 years of age residing in Hamilton County, Ohio hospitalized with acute gastroenteritis, and laboratory-confirmed rotavirus between 1997 and 2008 were identified through 2 independent surveillance systems: an active system with prospective enrollment of children admitted with acute gastroenteritis and a passive system of children identified by rotavirus testing as part of their usual medical care. Capture-recapture methods compared cases from both systems to estimate the number of missed cases from either system. Using census data for Hamilton County, rates per 10,000 with 95% confidence intervals (CI) for rotavirus hospitalizations were estimated. RESULTS: Overall, 486 cases were identified using active surveillance and 244 using passive surveillance, with 127 cases captured by both. Using capture-recapture methods, the overall rate in children <3 years old was 26.9/10,000; CI: 24.1, 30.6. Rates varied by year: highest in 1998 (48.1/10,000; CI: 32.4, 92.2) and lowest in 2008 (3.2/10,000; CI: 2.1, 6.1) after rotavirus vaccine introduction. Among children <5 years old, rates were highest in <3-month-old children (51.8/10,000; CI: 39.4, 75.1) and lowest in older age groups: 24 to 35 months (20.5/10,000; CI: 14.7, 30.3) and 36 to 59 months (4.1/10,000; CI: 2.9, 7.2). Rates from capture-recapture methods and adjusted active system were comparable. CONCLUSIONS: Capture-recapture methods were a useful tool to estimate rotavirus disease burden and to monitor trends, especially in the era of rotavirus immunization.

Factors associated with protective antibody levels to vaccine preventable diseases in internationally adopted children.

To determine which factors are predictive of protective antibody against vaccine-preventable diseases in internationally adopted children, we evaluated 562 children with serologic testing for at least one vaccine antigen before receiving a US vaccination. Vaccination status was defined as the number-of-doses recorded and as the presence of an up-to-date and valid record according to the American Academy of Pediatrics and the Advisory Committee on Immunization Practices guidelines. The number-of-doses recorded was the best predictor of protective antibody. These findings suggest that other options for immunization verification guidelines for internationally adopted children should be considered by policy makers.

Serologic testing to verify the immune status of internationally adopted children against vaccine preventable diseases.

Definitive immunization guidelines for internationally adopted children are lacking. We examined whether these children had serologic evidence of protection against vaccine-preventable diseases. For children with ≥3 vaccine doses, overall protection was high for diphtheria (85%), tetanus (95%), polio (93%), hepatitis B (77%), and Hib (67%). For children ≥12 months of age with ≥1 dose of measles, mumps, or rubella vaccines, 95%, 72%, and 94% were immune, respectively. Children without immunization documentation had lower immunity. Serologic testing was useful in verifying the immunization status in internationally adopted children with and without documentation of immunizations.

Hepatitis A in internationally adopted children: screening for acute and previous infections.

OBJECTIVE: The goal was to determine the prevalence of acute hepatitis A virus (HAV) infection and immunity among internationally adopted children. METHODS: Children seen at the International Adoption Center between September 25, 2006, and September 30, 2008, and were screened for HAV within 4 months after their arrival in the United States were eligible for the study. The age- and country-specific prevalence of acute HAV infection and immunity were determined. RESULTS: Overall, 288 children underwent HAV serological testing. Of the 279 with total HAV serological results, 29% had positive findings. Immunity varied according to region and country. The prevalence was lowest among children born in Asia/Pacific Rim region (17%) and highest among children born in Africa (72%). Only 13% of children <2 years of age were immune, compared with 80% of children 12 to 17 years of age (P = .002). Increasing age and birth region were associated independently with immunity. Positive HAV immunoglobulin M test results were found for 3 (1%) of 270 children; all were without symptoms. Their ages were 18, 27, and 41 months, and they were born in Kazakhstan, Russia, and the Latin America/Caribbean region, respectively. The father of 1 child developed HAV infection after arriving home. CONCLUSIONS: HAV immunity among internationally adopted children varied according to age and country of origin; 1% had acute infections. HAV screening is useful for determination of the need for HAV immunization and for prevention of transmission to family members and close contacts.

Contributions for repositioning a regional strategy for Healthy Municipalities, Cities and Communities (HM&C): results of a pan-American survey.

This article presents the results of the 1st Regional Survey of Healthy Municipalities, Cities and Communities (HM&C) carried out in 2008 by the Pan American Health Organization (PAHO) and ISALUD University of Argentina. It discusses the responses obtained from 12 countries in the Americas Region. Key informants in Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Mexico, Paraguay, Peru, and Uruguay were selected and encouraged to answer the survey, while informants from Canada and Honduras answered voluntarily and were included in this analysis. The discussion of the results of the Survey provides insight into the current status of HM&C in the Region and suggests key topics for repositioning the Regional strategy relative to: (1) the conceptual identity and tools for HM&C; (2) challenging areas in the implementation process (scale, legal framework, and development of capacities); (3) related strategies and participatory processes such as the ways citizen empowerment in governance is supported; (4) the need to monitor and assess the impact of the HM&C strategy on the health and quality of life of the populations involved; and (5) the need for developing a strategic research and training agenda. The analysis and discussion of these results aims to provide useful input for repositioning the strategy in the Region and contributing to the emergence of a second generation of concepts and tools capable of meeting the developing priorities and needs currently faced by the HM&C strategy.

Underestimates of intussusception rates among US infants based on inpatient discharge data: implications for monitoring the safety of rotavirus vaccines.

BACKGROUND: Because a previous rotavirus vaccine was associated with intussusception, new rotavirus vaccines are monitored postlicensure for any such association. Accurate background intussusception rates are needed to determine whether the number of cases observed after vaccination exceeds that expected by chance. Previously, intussusception rates were obtained from inpatient discharge databases. We sought to determine the rate of intussusception among infants managed only with short-stay or emergency department care. METHODS: Intussusception cases occurring in infants were identified retrospectively at 3 children's hospitals from January 2001 through March 2006, a period without rotavirus vaccine use, by a search of discharge, billing, and radiology databases for International Classification of Diseases, Ninth Revision, Clinical Modification code 560.0 (intussusception) and procedure codes and by review of medical records. RESULTS: Of 156 infants with intussusception fulfilling Brighton level 1 criteria, 81 (52%) were billed as inpatients, 68 (44%) as short-stay patients, and 7 (4%) as emergency department patients only. The use of only inpatients assigned code 560.0 underestimated the total number of level 1 cases at the hospitals by 44%. The mean annual intussusception rate for the hospitals' catchment counties was 49.3 cases per 100,000 live births (inpatient cases: 27.1 cases per 100,000 live births; short-stay or emergency department cases: 22.3 cases per 100,000 live births). CONCLUSIONS: Intussusception rates based solely on inpatient discharge databases could underestimate the true incidence of level 1 intussusception by >40%. Background rates used for assessment of risk after vaccination should account for cases managed only with short-stay or emergency department care.

Lessons learned from the application of a participatory evaluation methodology to healthy municipalities, cities and communities initiatives in selected countries of the Americas.

Health promotion has made significant strides in the past few decades in the Americas. Creating a healthy and supportive setting, also known as the settings approach, continues to be one of the most widely used health promotion strategies. Interest in evaluating the effectiveness of these strategies has been increasing greatly in the past few years. Participatory evaluation holds great promise for helping to generate this evidence and promote understanding of the factors that affect, positively or negatively, the advances of health promotion in the Region. During 2004-2006, a Participatory Evaluation methodology was introduced into several countries in the Americas through formal trainings conducted by the Pan American Health Organization (PAHO) in collaboration with country partners. This article summarizes the main lessons learned from the application of the participatory evaluation methodology in various countries in Latin America and the Caribbean. Factors affecting the evaluation of the initiatives were identified at multiple levels (individual, community, organizational, political, economic, etc.). Specific issues that were addressed included the political context, turnover of personnel in key institutions, concerns related to the effectiveness of participatory processes, and the existence of strong and sustained leadership at the country level. These factors are intertwined and affect each other in very complex ways, a fact that was reflected in the municipalities' experiences with participatory evaluation. Challenges included the ability to secure resources for the evaluation, the time needed to conclude the process, and working in an intersectoral manner. However, participating municipalities reported that the process of implementing a participatory evaluation and working with various stakeholders had an empowering effect: communities and stakeholders were more willing and interested in participating in health promotion initiatives in a sustained manner; alliances and intersectoral collaboration were strengthened; communication channels were opened; and municipalities were stimulated to review their planning and implementation processes in order to more appropriately incorporate health promotion principles. The article concludes with recommendations to improve the planning and implementation process of participatory evaluation efforts.