Exploring childhood immunization among undocumented migrants in Sweden - following qualitative study and the World Health Organizations Guide to Tailoring Immunization Programmes (TIP).

OBJECTIVES: National vaccination coverage in Sweden is high. Recurrent outbreaks of measles and rubella however highlight some immunity gaps in the population. Current knowledge about immunization status of undocumented migrant children is scant. The World Health Organization/Europe has developed the Guide to Tailoring Immunization Programmes (TIP) to assist countries in diagnosing barriers and motivators to vaccination in communities with low vaccination coverage. Based on the TIP guide, the objective of this study was to explore determinants to vaccination among undocumented immigrants, using qualitative approach. STUDY DESIGN: The study consisted of three steps: (i) an initial workshop for problem statement; (ii) qualitative research for increased understanding of the vaccination practices of children in the undocumented community; and (iii) a second workshop to incorporate the qualitative interview findings together with data from key stakeholders into a conceptual framework. METHODS: This was a qualitative study featuring interviews of seven undocumented parents recruited at non-governmental clinics, three nurses at Child Health Centers, and information from key stakeholders retrieved at workshops as part of the TIP process. RESULTS: The content analysis revealed two main themes: parental fear of being questioned and parental acceptance of child immunization. Undocumented parents had a positive view and attitude toward childhood immunization but expressed strong fear of being asked for identification papers at healthcare facilities. Owing to lack of knowledge on entitlements of the undocumented among health personnel, parents were incorrectly rejected when seeking care for their children. Frequent mobility among undocumented may limit access to complete the immunization schedule. Undocumented parents mistrust healthcare providers and avoid health facilities, further delaying childrens' access to health care, including immunization services. CONCLUSIONS: The findings of this study confirm the complexity of barriers that undocumented parents face regarding childhood immunization. The TIP guide offers a valuable process for a deeper understanding of the determinants of immunization challenges among undocumented migrants.

Motivations to participate in a Phase I/II HIV vaccine trial: A descriptive study from Dar es Salaam, Tanzania.

BACKGROUND: The search for an efficacious HIV vaccine is a global priority. To date only one HIV vaccine trial (RV144) has shown modest efficacy in a phase III trial. With existing different HIV-1 subtypes and frequent mutations, multiple trials are needed from different geographical sites particularly in sub-Saharan Africa where most HIV infections occur. Thus, motivations to participate in HIV vaccine trials among Tanzanians need to be assessed. This paper describes the motives of Police Officers who showed great interest to volunteer in HIVIS-03 in Dar es Salaam, Tanzania. METHODS: A descriptive cross-sectional study was conducted among Police Officers who showed interest to participate in the HIVIS-03, a phase I/II HIV vaccine trial in Dar es Salaam. Prior to detailed training sessions about HIV vaccine trials, the potential participants narrated their individual motives to participate in the trial on a piece of paper. Descriptive analysis using content approach and frequency distributions were performed. RESULTS: Of the 265 respondents, 242 (91.3%) provided their socio-demographic characteristics as well as reasons that would make them take part in the proposed trial. Majority, (39.7%), cited altruism as the main motive. Women were more likely to volunteer due to altruism compared to men (P < 0.01). Researchers' explanations about HIV/AIDS vaccine studies motivated 15.3%. More men (19.6%) than women (1.7%) were motivated to volunteer due to researchers' explanations (P < 0.001). Also, compared to other groups, those unmarried and educated up to secondary level of education were motivated to volunteer due to researchers' explanation (P < 0.05). Other reasons were: desire to become a role model (18.6%); to get knowledge for educating others (14.0%); to cooperate with researchers in developing an HIV vaccine (9.5%); to get protection against HIV infection (7.0%), and severity of the disease within families (6.2%). These results were supported by testimonies from both men and women. CONCLUSIONS: Participation in an HIV vaccine trial in a Tanzanian context is likely to be influenced by altruism and comprehensive education about the trial. Gender differences, marital status and education level need to be considered to enhance participation in future HIV vaccine trials.

Community perceptions of tuberculosis: A qualitative exploration from a gender perspective.

OBJECTIVE: To explore community laypersons' perspective on tuberculosis (TB)-related illness experiences, meanings, behaviours and impact with reference to gender. STUDY DESIGN: Qualitative, conducted in rural Bangladesh. METHODS: Eleven focus group discussions (FGDs) were conducted (six female and five male) in five subdistricts where the non-governmental organization BRAC operates. On average, seven purposively chosen poor, illiterate, non-TB patients participated in each FGD. Discussions were audiotaped, translated verbatim into English and analysed using MAXQDA software for qualitative data analysis, used it to assign codes to text segments to identify themes from participants' narratives. RESULTS: TB was recognized as a deadly disease that could affect anyone. The discussants were fairly aware of the psychological, financial and social impacts of TB. Women faced with adverse consequences more often than men, such as trouble in ongoing and prospective marital affairs. Coughing up sputum in public by women is culturally frowned upon, resulting in enormous suffering. Women tended to describe the clinical features more vaguely than men, and often specified fewer characteristic symptoms such as blood in sputum. CONCLUSIONS: The gender differences in the health and socio-economic impact of TB included perceived causality, curability, stigma, family and community support, fear of disclosure, and use of self-help or home remedies. Interactive health education covering various consequences of TB could be indispensable to changing negative beliefs.

Latent tuberculosis in pregnant women: a patient perspective.

SETTING: Screening and treatment for latent tuberculosis (LTBI) in pregnant women remains controversial, although studies suggest there is a significantly increased risk of progression to active disease in the postpartum period. Studies have also shown that adherence to postpartum follow-up and treatment of LTBI is poor. To our knowledge, the reasons for this have not been investigated. We therefore identified pregnant women originating from high-burden tuberculosis (TB) countries now living in the Stockholm region, and screened and treated them for LTBI.OBJECTIVE: To explore how women diagnosed with LTBI during pregnancy understood and experienced their diagnosis and treatment.DESIGN: Sixteen semi-structured interviews with women on treatment for LTBI were analysed using content analysis with an inductive approach.RESULTS: None of the women were familiar with LTBI and assumed they had active TB, causing anxiety about who they might have infected and how it would affect the baby, as well as the fear of being stigmatised. They showed great ability to search for and understand information regarding their condition. Once treatment was initiated, they were motivated to complete it.CONCLUSION: Our findings suggest that the key factors was to provide treatment along with reliable information about LTBI to help patients overcome their concerns and misconceptions.

Effect of different fractions of heparin on Plasmodium falciparum merozoite invasion of red blood cells in vitro.

Heparin and various heparin fractions were separated according to differences in molecular weight or affinity for antithrombin III and used for the inhibition of Plasmodium falciparum merozoite invasion of red blood cells in vitro. No variation in sensitivity to heparin was found among the four strains of P. falciparum tested; all required approximately 5 micrograms/ml (0.5 U/ml) of heparin for 50% inhibition of invasion. The most efficient fraction of heparin was the one with low affinity for antithrombin III. Its 50% inhibition concentration was 1 microgram/ml, indicating that it was more efficient than unfractionated heparin and other heparin fractions. The effect of heparin was reversible, since washing of heparin-treated cultures containing mainly schizonts showed no inhibition of merozoite invasion. The results suggest that a heparin fraction with no anticoagulant effect might be useful in the treatment of patients with falciparum malaria.

Human immune responses to the highly repetitive Plasmodium falciparum antigen Pf332.

The B and T cell responses to EB200, a repetitive part of the Plasmodium falciparum antigen Pf332, were examined in malaria-exposed Senegalese adults. Most donors had high levels of antibodies to recombinant EB200 and 17 overlapping peptides spanning EB200. Taking proliferation and/or cytokine (interferon-gamma and interleukin-4) production as a measure of T cell activation, eight of the EB200-derived peptides induced responses in > 40% of the donors tested. There was no general association between the different types of T cell responses measured, emphasizing the importance of including multiple parameters when analyzing T cell responses and suggesting that EB200 induces functionally distinct T cell responses. The most efficient peptide for induction of proliferative responses was one previously shown to induce T cell responses in five different H-2 congenic mouse strains primed with EB200, suggesting that this is a universal T cell epitope. The presence of multiple B and T cell epitopes in EB200, widely recognized by humans, is important since EB200 has been shown to elicit protective antibody responses in monkeys and may be considered for inclusion in malaria subunit vaccines.

The changing pattern of Plasmodium falciparum susceptibility to chloroquine but not to mefloquine in a mesoendemic area of Somalia.

The response of Plasmodium falciparum to chloroquine and mefloquine was investigated in a mesoendemic area of Somalia from 1986 to 1989. Serial in vivo field tests for chloroquine sensitivity were performed and the sensitivity in vitro to chloroquine and mefloquine was evaluated using the standard WHO in vitro microtest. Chloroquine treatment in vivo (25 mg base/kg body weight) resulted in parasite clearance in all patients within 7 d (S/RI) in 1986, while 17%, 19% and 30% RII/RIII responses were found in 1987, 1988 and 1989 respectively. There was consistent increase of parasite clearance time of the S/RI cases in all years. The sensitivity study in vitro in 1986 showed a low degree of chloroquine resistance in 3 of 29 isolates tested and a mean 50% effective dose (EC50) and EC99 of 0.34 x 10(-6) M and 1.99 x 10(-6) M, respectively. In contrast, in 1989, 12 of the 19 isolates tested were resistant to chloroquine. The mean EC50 and EC99 values had increased to 0.78 x 10(-6) M and 7.50 x 10(-6) M respectively. The data in vivo and in vitro indicate a rapid increase of chloroquine resistance both in frequency and degree. All isolates tested in 1986 and 1989 were fully inhibited by mefloquine at 3.2 x 10(-6) M, suggesting full sensitivity. Thus, increased resistance of P. falciparum to chloroquine did not significantly influence the sensitivity pattern of mefloquine.

Enzyme-linked staining method for light microscopic detection of antibodies to parasite antigens on the membrane of Plasmodium falciparum infected erythrocytes.

Indirect erythrocyte membrane immunofluorescence (EMIF), a standard method for detection of antibodies to the P. falciparum blood stage vaccine candidate antigen Pf155/RESA, has been adapted to light microscopy by enzyme-linked immunostaining of the erythrocyte membrane, using alkaline phosphatase and chromogenic substrate. This method gives a dark blue staining of the membranes of ring infected erythrocytes. Results obtained with 70 African sera in EMIF and in enzyme immunostaining correlated well although the enzyme based method sometimes resulted in higher antibody titers and appeared to be slightly more sensitive. Similar results were obtained when comparing immunofluorescence with enzyme immunostaining for detection of antibodies to intraerythrocytic parasite antigens. The enzyme linked immunostaining described is simple and fast and does not require expensive equipment and should, thus, be well suited for use in laboratories with limited resources or under field conditions.

T- and B-cell responses of malaria immune individuals to synthetic peptides corresponding to non-repeat sequences in the N-terminal region of the Plasmodium falciparum antigen Pf155/RESA.

While the C-terminal repeat region of Pf155/RESA, a Plasmodium falciparum vaccine candidate has been extensively studied for B- and T-cell reactivities, little is so far known about the non-repeat region in this respect. The present study aimed at investigating the non-repeat sequence 171-227 of Pf155/RESA for T- and B-cell epitopes. Eight overlapping peptides were synthesised and assayed for their ability to stimulate peripheral blood mononuclear cells obtained from P. falciparum-immune donors to proliferate and to induce secretion of interferon-gamma (IFN-gamma) and/or interleukin 4 (IL-4) using the ELISPOT assay. The plasmas of the corresponding donors were tested for antibody reactivity with the same peptides in ELISA. The individual cellular responses to the different peptides varied and in general they were not correlated, emphasising the importance of including several parameters for T-cell activation. The most frequent T-cell responses (proliferation, IFN-gamma and/or IL-4) were seen with two partially overlapping peptides corresponding to the sequences 171-185 and 181-195 that induced responses in 71 and 62% of the donors, respectively. Although, the frequency of responders was high, the magnitude of the responses was generally low. Two overlapping peptides corresponding to the sequence 186-206 bound antibodies from a large number of plasma samples. IL-4 producing cells were frequently found in donors whose sera contained antibodies to the corresponding peptide. However, there was no absolute correlation and many donors having anti-peptide antibodies could also be induced to produce IFN-gamma. In conclusion, the non-repeat region of Pf155/RESA contains several epitopes inducing functionally distinct T-cell responses. The sequence 171-206 was found to contain both B- and T-cell epitopes recognised by almost all individuals naturally primed to malaria. Thus, this sequence should be a useful tool in future immuno-epidemiological studies and/or for inclusion into a subunit vaccine against the asexual blood stages of the P. falciparum parasite.

Tuberculosis knowledge, attitudes and health-seeking behaviour in rural Uganda.

OBJECTIVES: To assess tuberculosis (TB) knowledge, attitudes and health-seeking behaviour to inform the design of communication and social mobilisation interventions. SETTING: Iganga/Mayuge Demographic Surveillance Site, Uganda. DESIGN: Between June and July 2008, 18 focus group discussions and 12 key informant interviews were conducted, including parents of infants and adolescents and key informant interviews with community leaders, traditional healers and patients with TB. RESULTS: People viewed TB as contagious, but not necessarily an airborne pathogen. Popular TB aetiologies included sharing utensils, heavy labour, smoking, bewitchment and hereditary transmission. TB patients were perceived to seek care late or to avoid care. Combining care from traditional healers and the biomedical system was common. Poverty, drug stock-outs, fear of human immunodeficiency virus (HIV) testing and length of TB treatment negatively affect health-seeking behaviour. Stigma and avoidance of persons with TB often reflects an assumption of HIV co-infection. CONCLUSION: The community's concerns about pill burden, quality of care, financial barriers, TB aetiology, stigma and preference for pluralistic care need to be addressed to improve early detection. Health education messages should emphasise the curability of TB, the feasibility of treatment and the engagement of traditional healers as partners in identifying cases and facilitating adherence to treatment.