Modeling the Cost of Vaccinating a Measles Zero-Dose Child in Zambia Using Three Vaccination Strategies.

Countries with moderate to high measles-containing vaccine coverage face challenges in reaching the remaining measles zero-dose children. There is growing interest in targeted vaccination activities to reach these children. We developed a framework for prioritizing districts for targeted measles and rubella supplementary immunization activities (SIAs) for Zambia in 2020, incorporating the use of the WHO's Measles Risk Assessment Tool (MRAT) and serosurveys. This framework was used to build a model comparing the cost of vaccinating one zero-dose child under three vaccination scenarios: standard nationwide SIA, targeted subnational SIA informed by MRAT, and targeted subnational SIA informed by both MRAT and measles seroprevalence data. In the last scenario, measles seroprevalence data are acquired via either a community-based serosurvey, residual blood samples from health facilities, or community-based IgG point-of-contact rapid diagnostic testing. The deterministic model found that the standard nationwide SIA is the least cost-efficient strategy at 13.75 USD per zero-dose child vaccinated. Targeted SIA informed by MRAT was the most cost-efficient at 7.63 USD per zero-dose child, assuming that routine immunization is just as effective as subnational SIA in reaching zero-dose children. Under similar conditions, a targeted subnational SIA informed by both MRAT and seroprevalence data resulted in 8.17-8.35 USD per zero-dose child vaccinated, suggesting that use of seroprevalence to inform SIA planning may not be as cost prohibitive as previously thought. Further refinement to the decision framework incorporating additional data may yield strategies to better target the zero-dose population in a financially feasible manner.

Who is missed in a community-based survey: Assessment and implications of biases due to incomplete sampling frame in a community-based serosurvey, Choma and Ndola Districts, Zambia, 2022.

Community-based serological studies are increasingly relied upon to measure disease burden, identify population immunity gaps, and guide control and elimination strategies; however, there is little understanding of the potential for and impact of sampling biases on outcomes of interest. As part of efforts to quantify measles immunity gaps in Zambia, a community-based serological survey using stratified multi-stage cluster sampling approach was conducted in Ndola and Choma districts in May-June 2022, enrolling 1245 individuals. We carried out a follow-up study among individuals missed from the sampling frame of the serosurvey in July-August 2022, enrolling 672 individuals. We assessed the potential for and impact of biases in the community-based serosurvey by i) estimating differences in characteristics of households and individuals included and excluded (77% vs 23% of households) from the sampling frame of the serosurvey and ii) evaluating the magnitude these differences make on healthcare-seeking behavior, vaccination coverage, and measles seroprevalence. We found that missed households were 20% smaller and 25% less likely to have children. Missed individuals resided in less wealthy households, had different distributions of sex and occupation, and were more likely to seek care at health facilities. Despite these differences, simulating a survey in which missed households were included in the sampling frame resulted in less than a 5% estimated bias in these outcomes. Although community-based studies are upheld as the gold standard study design in assessing immunity gaps and underlying community health characteristics, these findings underscore the fact that sampling biases can impact the results of even well-conducted community-based surveys. Results from these studies should be interpreted in the context of the study methodology and challenges faced during implementation, which include shortcomings in establishing accurate and up-to-date sampling frames. Failure to account for these shortcomings may result in biased estimates and detrimental effects on decision-making.

Challenges Addressing Inequalities in Measles Vaccine Coverage in Zambia through a Measles-Rubella Supplementary Immunization Activity during the COVID-19 Pandemic.

BACKGROUND: Measles-rubella supplementary immunization activities (MR-SIAs) are conducted to address inequalities in coverage and fill population immunity gaps when routine immunization services fail to reach all children with two doses of a measles-containing vaccine (MCV). We used data from a post-campaign coverage survey in Zambia to measure the proportion of measles zero-dose and under-immunized children who were reached by the 2020 MR-SIA and identified reasons associated with persistent inequalities following the MR-SIA. METHODS: Children between 9 and 59 months were enrolled in a nationally representative, cross-sectional, multistage stratified cluster survey in October 2021 to estimate vaccination coverage during the November 2020 MR-SIA. Vaccination status was determined by immunization card or through caregivers' recall. MR-SIA coverage and the proportion of measles zero-dose and under-immunized children reached by MR-SIA were estimated. Log-binomial models were used to assess risk factors for missing the MR-SIA dose. RESULTS: Overall, 4640 children were enrolled in the nationwide coverage survey. Only 68.6% (95% CI: 66.7%, 70.6%) received MCV during the MR-SIA. The MR-SIA provided MCV1 to 4.2% (95% CI: 0.9%, 4.6%) and MCV2 to 6.3% (95% CI: 5.6%, 7.1%) of enrolled children, but 58.1% (95% CI: 59.8%, 62.8%) of children receiving the MR-SIA dose had received at least two prior MCV doses. Furthermore, 27.8% of measles zero-dose children were vaccinated through the MR-SIA. The MR-SIA reduced the proportion of measles zero-dose children from 15.1% (95% CI: 13.6%, 16.7%) to 10.9% (95% CI: 9.7%, 12.3%). Zero-dose and under-immunized children were more likely to miss MR-SIA doses (prevalence ratio (PR): 2.81; 95% CI: 1.80, 4.41 and 2.22; 95% CI: 1.21 and 4.07) compared to fully vaccinated children. CONCLUSIONS: The MR-SIA reached more under-immunized children with MCV2 than measles zero-dose children with MCV1. However, improvement is needed to reach the remaining measles zero-dose children after SIA. One possible solution to address the inequalities in vaccination is to transition from nationwide non-selective SIAs to more targeted and selective strategies.

Instrumented Gait Analysis (IGA) for Management of Children With Cerebral Palsy: A Needs Assessment Survey.

PURPOSE: This needs assessment survey identifies the priorities of the clinical and research communities involved with the use of instrumented gait analysis (IGA) for a clinical practice guideline on IGA use with children with cerebral palsy (CP). METHODS: Thirteen Likert scale questions asked about the importance of topics related to IGA. Other questions addressed respondents' demographics, experience with IGA, patient populations, and gait laboratory characteristics. Several open-ended questions were included and analyzed. RESULTS: The survey was completed by 43 physical therapists and 53 non-physical therapists involved with IGA. More than 90% rated the following as critically or highly important: reliability and validity of IGA to identify gait pathology (94%); ability to longitudinally track gait pathology (93%); use in planning interventions (93%); use in evaluating outcomes (93%); and definition of IGA (90%). CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE: This needs assessment survey identified the topic priorities of clinicians and practitioners who use IGA for the management of children with CP. These results will guide the development of a clinical practice guideline on the use of IGA for the management of CP.

Estimating the health impact of vaccination against ten pathogens in 98 low-income and middle-income countries from 2000 to 2030: a modelling study.

BACKGROUND: The past two decades have seen expansion of childhood vaccination programmes in low-income and middle-income countries (LMICs). We quantify the health impact of these programmes by estimating the deaths and disability-adjusted life-years (DALYs) averted by vaccination against ten pathogens in 98 LMICs between 2000 and 2030. METHODS: 16 independent research groups provided model-based disease burden estimates under a range of vaccination coverage scenarios for ten pathogens: hepatitis B virus, Haemophilus influenzae type B, human papillomavirus, Japanese encephalitis, measles, Neisseria meningitidis serogroup A, Streptococcus pneumoniae, rotavirus, rubella, and yellow fever. Using standardised demographic data and vaccine coverage, the impact of vaccination programmes was determined by comparing model estimates from a no-vaccination counterfactual scenario with those from a reported and projected vaccination scenario. We present deaths and DALYs averted between 2000 and 2030 by calendar year and by annual birth cohort. FINDINGS: We estimate that vaccination of the ten selected pathogens will have averted 69 million (95% credible interval 52-88) deaths between 2000 and 2030, of which 37 million (30-48) were averted between 2000 and 2019. From 2000 to 2019, this represents a 45% (36-58) reduction in deaths compared with the counterfactual scenario of no vaccination. Most of this impact is concentrated in a reduction in mortality among children younger than 5 years (57% reduction [52-66]), most notably from measles. Over the lifetime of birth cohorts born between 2000 and 2030, we predict that 120 million (93-150) deaths will be averted by vaccination, of which 58 million (39-76) are due to measles vaccination and 38 million (25-52) are due to hepatitis B vaccination. We estimate that increases in vaccine coverage and introductions of additional vaccines will result in a 72% (59-81) reduction in lifetime mortality in the 2019 birth cohort. INTERPRETATION: Increases in vaccine coverage and the introduction of new vaccines into LMICs have had a major impact in reducing mortality. These public health gains are predicted to increase in coming decades if progress in increasing coverage is sustained. FUNDING: Gavi, the Vaccine Alliance and the Bill & Melinda Gates Foundation.

Intimate partner violence and symptoms of reproductive tract infections among married Indian women.

OBJECTIVE: To assess the association of 3 types of intimate partner violence (IPV)-verbal, physical, and sexual-with self-reported symptoms of reproductive tract infections (RTIs) among married Indian women. METHODS: A cross-sectional analysis of population-based data from the 2005-2006 Indian National Family Health Survey-3 was conducted. The sample comprised 65610 married Indian women of reproductive age (15-49years). RESULTS: Overall, 23.9% of women experienced at least 1 type of IPV, and 9.6% reported at least 1 RTI symptom in the year preceding the survey. Verbal, physical, and sexual IPV each demonstrated a significant independent effect on the reporting of genital sores and abnormal genital discharge. Additionally, the more types of IPV a woman experienced, the higher her odds of also reporting genital sores and abnormal genital discharge. CONCLUSION: No single type of IPV explains women's risk of RTIs; rather, there are multiple pathways by which women's experience of IPV can result in RTIs. Sexual and reproductive healthcare that incorporates IPV support services is needed to meet the special needs of abused women. Additionally, RTI screening should be considered by non-governmental organizations providing care for women who have experienced IPV, especially those who report multiple types of violence.

WIC participation and breastfeeding among White and Black mothers: data from Mississippi.

Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been associated with lower rates of breastfeeding; studies have suggested this relationship may be modified by race. The purpose of this study is to examine the association between WIC participation and breastfeeding behaviors among white and black women in Mississippi. Using data from the 2004-2008 Mississippi Pregnancy Risk Assessment Monitoring System, we calculated multivariable prevalence and hazard ratios to assess the relationships among WIC participation during pregnancy and breastfeeding initiation and duration through 10 weeks postpartum. Stratified analyses were performed for white and black women. 52.2 % of white and 82.1 % of black women participated in WIC. 60.4 % of white and 39.7 % of black women initiated breastfeeding, and 26.5 % and 21.9 %, respectively, were breastfeeding at 10 weeks postpartum. WIC participation was negatively associated with breastfeeding initiation among whites (APR: 0.87; 95 % CI 0.77-0.99), but not blacks (APR: 0.99; 95 % CI 0.28-1.21). WIC participation was not associated with breastfeeding duration for women of either race (white: AHR: 1.05, 95 % CI 0.80-1.38; black: AHR: 0.91, 95 % CI 0.65-1.26). The results among white women suggest that Mississippi WIC might benefit from an in depth evaluation of the program's breastfeeding promotional activities to determine if aspects of the program are undermining breastfeeding initiation. High rates of participation in the WIC program among black women, and the overall low rates of breastfeeding in this population point to the potential the program has to increase breastfeeding rates among blacks.

Community environments shaping transactional sex among sexually active men in Malawi, Nigeria, and Tanzania.

Transactional sex, or the exchange of sex for material goods or money, is a risky sexual behavior that has been linked to HIV/AIDS and gender-based violence. Throughout sub-Saharan Africa, transactional sex remains a common practice, putting men and women at risk of HIV. However, little is known of how community environments shape men's participation in risky transactional sex. This analysis examines community-level influences on participation in risky transactional sex among sexually active men in three African countries (Malawi, Tanzania, and Nigeria). The analysis uses Demographic and Health Survey (DHS) data to examine the association between men's report of risky transactional sex and community characteristics including economic, gender norms, HIV behavior and knowledge, and demographic factors. The results show that men residing in communities with more female education and later age of first birth are less likely to report risky transactional sex, while men who live in communities where men report higher number of sexual partners are more likely to report risky transactional sex. While programmatic interventions should continue to improve women's status individually and relative to men, such efforts should be extended to recognize that many community and cultural influences also affect men's sexual behavior. Programs that understand, discuss, and challenge community factors that influence men's sexual behavior may be able to provide a more effective intervention resulting in opportunities for communities to initiate behavioral change.