Measuring Zero-Dose Children: Reflections on Age Cohort Flexibilities for Targeted Immunization Surveys at the Local Level.

Zero-dose (ZD) children is a critical objective in global health, and it is at the heart of the Immunization Agenda 2030 (IA2030) strategy. Coverage for the first dose of diphtheria-tetanus-pertussis (DTP1)-containing vaccine is the global operational indicator used to estimate ZD children. When surveys are used, DTP1 coverage estimates usually rely on information reported from caregivers of children aged 12-23 months. It is important to have a global definition of ZD children, but learning and operational needs at a country level may require different ZD measurement approaches. This article summarizes a recent workshop discussion on ZD measurement for targeted surveys at local levels related to flexibilities in age cohorts of inclusion from the ZD learning Hub (ZDLH) initiative-a learning initiative involving 5 consortia of 14 different organizations across 4 countries-Bangladesh, Mali, Nigeria, and Uganda-and a global learning partner. Those considerations may include the need to generate insights on immunization timeliness and on catch-up activities, made particularly relevant in the post-pandemic context; the need to compare results across different age cohort years to better identify systematically missed communities and validate programmatic priorities, and also generate insights on changes under dynamic contexts such as the introduction of a new ZD intervention or for recovering from the impact of health system shocks. Some practical considerations such as the potential need for a larger sample size when including comparisons across multiple cohort years but a potential reduction in the need for household visits to find eligible children, an increase in recall bias when older age groups are included and a reduction in recall bias for the first year of life, and a potential reduction in sample size needs and time needed to detect impact when the first year of life is included. Finally, the inclusion of the first year of life cohort in the survey may be particularly relevant and improve the utility of evidence for decision-making and enable its use in rapid learning cycles, as insights will be generated for the population being currently targeted by the program. For some of those reasons, the ZDLH initiative decided to align on a recommendation to include the age cohort from 18 weeks to 23 months, with enough power to enable disaggregation of key results across the two different cohort years. We argue that flexibilities with the age cohort for inclusion in targeted surveys at the local level may be an important principle to be considered. More research is needed to better understand in which contexts improvements in timeliness of DTP1 in the first year of life will translate to improvements in ZD results in the age cohort of 12-23 months as defined by the global DTP1 indicator.

Endoscopic scoring system utilization for inflammatory bowel disease activity assessment: A multicenter real-world study from Argentina.

BACKGROUND: The frequency and patterns of use of scores for the assessment of endoscopic activity in inflammatory bowel disease patients are not known. AIM: To describe the prevalence of adequate use of endoscopic scores in IBD patients who underwent colonoscopy in a real-life setting. MATERIALS AND METHODS: A multicenter observational study comprising six community hospitals in Argentina was undertaken. Patients with a diagnosis of Crohn's disease or ulcerative colitis who underwent colonoscopy for endoscopic activity assessment between 2018 and 2022 were included. Colonoscopy reports of included subjects were manually reviewed to determine the proportion of colonoscopies that included an endoscopic score report. We determined the proportion of colonoscopy reports that included all of the IBD colonoscopy report quality elements proposed by BRIDGe group. Endoscopist's specialty, years of experience as well as expertise in IBD were assessed. RESULTS: A total of 1556 patients were included for analysis (31.94% patients with Crohn's disease). Mean age was 45.94±15.46. Endoscopic score reporting was found in 58.41% of colonoscopies. Most frequently used scores were Mayo endoscopic score (90.56%) and SES-CD (56.03%) for ulcerative colitis and Crohn's disease, respectively. In addition, 79.11% of endoscopic reports failed to comply with all recommendations on endoscopic reporting for inflammatory bowel disease. CONCLUSIONS: A significant proportion of endoscopic reports of inflammatory bowel disease patients do not include the description of an endoscopic score to assess mucosal inflammatory activity in a real-world setting. This is also associated with a lack of compliance in recommended criteria for proper endoscopic reporting.

Vaccine wastage in Ghana, Mozambique, and Pakistan: An assessment of wastage rates for four vaccines and the context, causes, drivers, and knowledge, attitudes and practices for vaccine wastage.

Vaccine procurement costs comprise a significant share of immunization program costs in low- and middle-income countries, yet not all procured vaccines are administered. Vaccine wastage occurs due to vial breakage, excessive heat or freezing, expiration, or when not all doses in a multidose vial are used. Better estimates of vaccine wastage rates and their causes could support improved management of vaccine stocks and reduce procurement costs. This study examined aspects of wastage for four vaccines at service delivery points in Ghana (n = 48), Mozambique (n = 36), and Pakistan (n = 46). We used prospective data from daily and monthly vaccine usage data entry forms, along with cross-sectional surveys, and in-depth interviews. The analysis found that estimated monthly proportional open-vial wastage rates for vaccines in single-dose vials (SDV) or in multi-dose vials (MDV) that can be kept refrigerated up to four weeks after opening ranged from 0.08 % to 3 %. For MDV where remaining doses are discarded within six hours after opening, the mean wastage rates ranged from 5 % to 33 %, with rates being highest for measles containing vaccine. Despite national-level guidance to open a vaccine vial even when only one child is present, vaccines in MDV that are discarded within six hours of opening are sometimes offered less frequently than vaccines in SDV or in MDV where remaining doses can be used for up to 4 weeks. This practice can lead to missed opportunities for vaccination. While closed-vial wastage at service delivery points (SDPs) was relatively rare, individual instances can result in large losses, suggesting that monitoring closed-vial wastage should not be neglected. Health workers reported insufficient knowledge of vaccine wastage tracking and reporting methods. Improving reporting forms would facilitate more accurate reporting of all causes of wastage, as would additional training and supportive supervision. Globally, decreasing doses per vial could reduce open-vial wastage.

Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children.

BACKGROUND: Understanding past successes in reaching unvaccinated or "zero-dose" children can help inform strategies for improving childhood immunization in other settings. Drawing from positive outlier methods, we developed a novel approach for identifying potential exemplars in reducing zero-dose children. METHODS: Focusing on 2000-2019, we assessed changes in the percentage of under-one children with no doses of the diphtheria-tetanus-pertussis vaccine (no-DTP) across two geographic dimensions in 56 low- or lower-middle-income countries: (1) national levels; (2) subnational gaps, as defined as the difference between the 5th and 95th percentiles of no-DTP prevalence across second administrative units. Countries with the largest reductions for both metrics were considered positive outliers or potential 'exemplars', demonstrating exception progress in reducing national no-DTP prevalence and subnational inequalities. Last, so-called "neighborhood analyses" were conducted for the Gavi Learning Hub countries (Nigeria, Mali, Uganda, and Bangladesh), comparing them with countries that had similar no-DTP measures in 2000 but different trajectories through 2019. RESULTS: From 2000 to 2019, the Democratic Republic of the Congo, Ethiopia, and India had the largest absolute decreases for the two no-DTP dimensions-national prevalence and subnational gaps-while Bangladesh and Burundi registered the largest relative reductions for each no-DTP metric. Neighborhood analyses highlighted possible opportunities for cross-country learning among Gavi Learning Hub countries and potential exemplars in reducing zero-dose children. CONCLUSIONS: Identifying where exceptional progress has occurred is the first step toward better understanding how such gains could be achieved elsewhere. Further examination of how countries have successfully reduced levels of zero-dose children-especially across variable contexts and different drivers of inequality-could support faster, sustainable advances toward greater vaccination equity worldwide.

Mapping of Pro-Equity Interventions Proposed by Immunisation Programs in Gavi Health Systems Strengthening Grants.

Reaching zero-dose (ZD) children, operationally defined as children who have not received a first dose of the diphtheria, tetanus, and pertussis (DTP1) vaccine, is crucial to increase equitable immunisation coverage and access to primary health care. However, little is known about the approaches already taken by countries to improve immunisation equity. We reviewed all Health System Strengthening (HSS) proposals submitted by Gavi-supported countries from 2014 to 2021 inclusively and extracted information on interventions favouring equity. Pro-equity interventions were mapped to an analytical framework representing Gavi 5.0 programmatic guidance on reaching ZD children and missed communities. Data from keyword searches and manual screening were extracted into an Excel database. Open format responses were analysed using inductive and deductive thematic coding. Data analysis was conducted using Excel and R. Of the 56 proposals included, 51 (91%) included at least one pro-equity intervention. The most common interventions were conducting outreach sessions, tailoring the location of service delivery, and partnerships. Many proposals had "bundles" of interventions, most often involving outreach, microplanning and community-level education activities. Nearly half prioritised remote-rural areas and only 30% addressed gender-related barriers to immunisation. The findings can help identify specific interventions on which to focus future evidence syntheses, case studies and implementation research and inform discussions on what may or may not need to change to better reach ZD children and missed communities moving forward.

Otimização na apuração e análise de custo do Hospital de Alvorada

O presente projeto apresentado terá por finalidde a otimização da apuração e análise de custos do Hospital de Alvorada. Tal otimização se dará através da implantação de um sistema de custos(módulo que pertence ao Sistema MV1) já em vigência na Fundação Universitária de cardiologia. Além da implantação desse sistema de custos, o mesmo precisará ser alimentado por dados dos outros setores. Para isso acontecer outros módulos derão ser também implementados nas áreas assistenciais, de apoio e administrativa e os colaboradores treinados. O sistema de custos vai proporcionar para as chefias dos setores gerência administrativa e os diretores do hospital, a ciência referente às receitas e gastos através das informações geradas com uma dinâmica mais ágil, obtendo maior conhecimento e orientação para a tomada de decisão. Serão criados indicadores de desempenho para o acompanhamento mais efetivo das receitas e gastos dos setores.

A necessidade da regulação do setor privado de saúde no Brasil: razões e perspectivas / Necessity of the regulation of the private sector of health in Brazil: reasons and perspectives

Com o objetivo de conhecer as razões que levaram o governo brasileiro a regular o mercado de saúde,este trabalho disserta sobre a história desse mercado, sua situação atual, passando pelos conceitos de “falhas de governo” e pelos conceitos mercadológicos de “falhas de mercado” (entre eles, assimetria de informações, externalidades, risco moral e seleção adversa), associando-os sempre ao mercado do país. No discorrer desta pesquisa, foram incluídas algumas sugestões encontradas na literatura, vislumbradas como perspectiva futura para o mercado e, ao fim, conclui-se que é necessário melhorar os mecanismos de coleta de dados e de integração com o sistema público, além de ser imperioso o direcionamento das operadoras, por meio de medidas regulatórias para um sistema de saúde com base na prevenção de doenças em vez de baseado em estratégia assistencialista