Formation of Interpersonal Competencies Through Interprofessional Simulation: Nursing and Medicine.

AIM: The aim of this study was to analyze the process of interpersonal competencies formation in nursing and medical students who participated in a standardized interprofessional clinical simulation. BACKGROUND: Interprofessional education in health sciences has had an important impact on the development of relational qualities centered on the patient. METHOD: The study followed a qualitative interpretive approach with students. Students who participated in clinical simulation activities were asked about their experiences and their learning process with respect to interpersonal competencies. A thematic analysis of the data was performed. RESULTS: Three themes emerged: 1) approaching the practice with uncertainty and fear of new relationships, 2) reflecting on decisions while recognizing distinctive roles, and 3) recognizing the human sense of practice while developing skills for caring and curing. CONCLUSION: Students underwent this process and learned about empathy, communication, critical reflexive thinking, and teamwork.

HPV vaccination introduction worldwide and WHO and UNICEF estimates of national HPV immunization coverage 2010-2019.

WHO/UNICEF estimates for HPV vaccination coverage from 2010 to 2019 are analyzed against the backdrop of the 90% coverage target for HPV vaccination by 2030 set in the recently approved global strategy for cervical cancer elimination as a public health problem. As of June 2020, 107 (55%) of the 194 WHO Member States have introduced HPV vaccination. The Americas and Europe are by far the WHO regions with the most introductions, 85% and 77% of their countries having already introduced respectively. A record number of introductions was observed in 2019, most of which in low- and middle- income countries (LMIC) where access has been limited. Programs had an average performance coverage of around 67% for the first dose and 53% for the final dose of HPV. LMICs performed on average better than high- income countries for the first dose, but worse for the last dose due to higher dropout. Only 5 (6%) countries achieved coverages with the final dose of more than 90%, 22 countries (21%) achieved coverages of 75% or higher while 35 (40%) had a final dose coverage of 50% or less. When expressed as world population coverage (i.e., weighted by population size), global coverage of the final HPV dose for 2019 is estimated at 15%. There is a long way to go to meet the 2030 elimination target of 90%. In the post-COVID era attention should be paid to maintain the pace of introductions, specially ensuring the most populous countries introduce, and further improving program performance globally.

Assessing electronic immunization registries: the Pan American Health Organization experience.

OBJECTIVE: To develop a methodology to assess electronic immunization registries (EIRs) in low- and middle-income countries (LMICs) in Latin America and the Caribbean. METHODS: A team from the Immunization Unit at the Pan American Health Organization (PAHO) reviewed existing methodologies to evaluate health information systems, particularly the Performance of Routine Information System Management (PRISM) framework and methodologies used to assess information systems. In 2014, the PAHO team convened a small working group to develop an evaluation approach to be added to the existing World Health Organization immunization data quality self-assessment (DQS) tool. The resulting DQS with an added EIR component was named "DQS Plus." The DQS Plus methodology was used in Panama in May 2014 and in Honduras in November 2015. RESULTS: The DQS Plus tool proved feasible and easy to implement in Panama and Honduras, including by not adding much time or resources to those needed for a usual DQS. The information obtained from the DQS Plus assessment was practical and helped provide health authorities with recommendations to update and improve their EIR, strengthen the use of the registry, and enhance the data the assessment produced, at all levels of the health system. These recommendations are currently being implemented in the two countries. CONCLUSIONS: The DQS Plus proved to be a practical and useful approach for assessing an EIR in an LMIC and generating actionable recommendations. Further work on defining operational and related EIR functional standards in LMICs will help develop an improved EIR assessment tool for Latin America and the Caribbean, and potentially elsewhere.

Progress in vaccination towards hepatitis B control and elimination in the Region of the Americas.

BACKGROUND: Over recent decades, the Region of the Americas has made significant progress towards hepatitis B elimination. We summarize the countries/territories' efforts in introducing and implementing hepatitis B (HB) vaccination and in evaluating its impact on HB virus seroprevalence. METHODS: We collected information about HB vaccination schedules, coverage estimates, and year of vaccine introduction from countries/territories reporting to the Pan American Health Organization/World Health Organization (PAHO/WHO) through the WHO/UNICEF Joint Reporting Form on Immunization. We obtained additional information regarding countries/territories vaccination recommendations and strategies through communications with Expanded Program on Immunization (EPI) managers and national immunization survey reports. We identified vaccine impact studies conducted and published in the Americas. RESULTS: As of October 2016, all 51 countries/territories have included infant HB vaccination in their official immunization schedule. Twenty countries, whose populations represent over 90% of the Region's births, have included nationwide newborn HB vaccination. We estimated at 89% and 75%, the regional three-dose series and the birth dose HB vaccination coverage, respectively, for 2015. The impact evaluations of infant HB immunization programs in the Region have shown substantial reductions in HB surface antigen (HBsAg) seroprevalence. CONCLUSION: The achievements of vaccination programs in the Americas suggest that the elimination of perinatal and early childhood HB transmission could be feasible in the short-term. Moreover, the data gathered indicate that the Region may have already achieved the 2020 WHO goal for HB control.

The Impact of the Coronavirus Pandemic on Vaccination Coverage in Latin America and the Caribbean.

BACKGROUND: Routine vaccination coverage in Latin America and the Caribbean declined prior to and during the coronavirus pandemic. We assessed the pandemic's impact on national coverage levels and analyzed whether financial and inequality indicators, immunization policies, and pandemic policies were associated with changes in national and regional coverage levels. METHODOLOGY: We compared first- and third-dose coverage of diphtheria-pertussis-tetanus-containing vaccine (DTPcv) with predicted coverages using time series forecast modeling for 39 LAC countries and territories. Data were from the PAHO/WHO/UNICEF Joint Reporting Form. A secondary analysis of factors hypothesized to affect coverages during the pandemic was also performed. RESULTS: In total, 31 of 39 countries and territories (79%) had greater-than-predicted declines in DTPcv1 and DTPcv3 coverage during the pandemic, with 9 and 12 of these, respectively, falling outside the 95% confidence interval. Within-country income inequality (i.e., Gini coefficient) was associated with significant declines in DTPcv1 coverage, and cross-country income inequality was associated with declines in DTPcv1 and DTPcv3 coverages. Observed absolute and relative inequality gaps in DTPcv1 and DTPcv3 coverage between extreme country quintiles of income inequality (i.e., Q1 vs. Q5) were accentuated in 2021, as compared with the 2019 observed and 2021 predicted values. We also observed a trend between school closures and greater-than-predicted declines in DTPcv3 coverage that approached statistical significance (p = 0.06). CONCLUSION: The pandemic exposed vaccination inequities in LAC and significantly impacted coverage levels in many countries. New strategies are needed to reattain high coverage levels.

Seasonal influenza vaccination in the Americas: Progress and challenges during the COVID-19 pandemic.

BACKGROUND: Vaccination is one of the most effective measures to prevent influenza illness and its complications; influenza vaccination remained important during the COVID-19 pandemic to prevent additional burden on health systems strained by COVID-19 demand. OBJECTIVES: We describe policies, coverage, and progress of seasonal influenza vaccination programs in the Americas during 2019-2021 and discuss challenges in monitoring and maintaining influenza vaccination coverage among target groups during the COVID-19 pandemic. METHODS: We used data on influenza vaccination policies and vaccination coverage reported by countries/territories via the electronic Joint Reporting Form on Immunization (eJRF) for 2019-2021. We also summarized country vaccination strategies shared with PAHO. RESULTS: As of 2021, 39 (89 %) out of 44 reporting countries/territories in the Americas had policies for seasonal influenza vaccination. Countries/territories adapted health services and immunization delivery strategies using innovative approaches, such as new vaccination sites and expanded schedules, to ensure continuation of influenza vaccination during the COVID-19 pandemic. However, among countries/territories that reported data to eJRF in both 2019 and 2021, median coverage decreased; the percentage point decrease was 21 % (IQR = 0-38 %; n = 13) for healthcare workers, 10 % (IQR = -1.5-38 %; n = 12) for older adults, 21 % (IQR = 5-31 %; n = 13) for pregnant women, 13 % (IQR = 4.8-20.8 %; n = 8) for persons with chronic diseases, and 9 % (IQR = 3-27 %; n = 15) for children. CONCLUSIONS: Countries/territories in the Americas successfully adapted influenza vaccination delivery to continue vaccination services during the COVID-19 pandemic; however, reported influenza vaccination coverage decreased from 2019 to 2021. Reversing declines in vaccination will necessitate strategic approaches that prioritize sustainable vaccination programs across the life course. Efforts should be made to improve the completeness and quality of administrative coverage data. Lessons learned from COVID-19 vaccination, such as the rapid development of electronic vaccination registries and digital certificates, might facilitate advances in coverage estimation.

Promoting immunization equity in Latin America and the Caribbean: Case studies, lessons learned, and their implication for COVID-19 vaccine equity.

In 2020, the World Health Organization launched the Immunization Agenda 2030: A Global Strategy to Leave No One Behind, which prioritizes high equitable immunization coverage at the national level and in all districts. Achieving high and homogenous immunization coverage, which is all the more important within the current context of the COVID-19 pandemic and vaccine rollout, requires the strengthening of existing immunization activities and innovative approach to immunization promotion. This research applied a descriptive case study methodology to document the implementation of strategic multi-level alliances to promote equitable immunization access and demand in Colombia, Guyana, and Sucre, Bolivia. Data collection, carried out between September 2019 and March 2020, included documentary reviews, semi-structured interviews, focus groups, and site visits accompanied by discussions with relevant stakeholders. Case studies provide valuable examples of people-centered, partnership-based, country-owned, and data-guided approaches to promoting equitable immunization coverage, including multi-level partnerships to build technical capacity for the identification and measurement of social inequalities impacting immunization in Colombia; intersectoral and community collaboration for pro-equity emergency response to regional vaccine preventable disease outbreaks in Guyana; and strategic alliances with the education sector and civil society organizations for the introduction of the human papilloma virus (HPV) vaccine in Sucre, Bolivia. Lessons learned highlight avenues for improving the impact of multi-level, equity-focused capacity building, particularly at the local level; optimizing the use of data and resources, partnerships, and community and stakeholder education and empowerment. While impact studies are needed to better understand the quantitative contributions of such strategic alliances, these case studies illustrate their practical significance and reinforce the value of multi-level, intersectoral collaboration for enhancing equitable immunization access and demand. The experiences of Colombia, Guyana, and Sucre, Bolivia provide evidence-based insight to support pro-equity immunization program planning to ensure that no one is left behind and that everyone, everywhere receives the benefits of vaccines, both routine and for COVID-19.

Higher education managers' perspectives on quality management and technology acceptance: A tale of elders, mediators, and working bees in times of Covid-19.

The Covid-19 pandemic has emphasized the role of educational management information systems (EMIS) for quality management (QM) in higher education, and set new directions for post-pandemic studies. Successful implementation of QM processes depends largely on managers' perceptions about quality and educational technology. However, higher education managers' profiles regarding these quality perceptions and their EMIS acceptance have been insufficiently investigated so far. In response to this research gap, we identified such profiles based on a quantitative survey of N = 70 managers from Chilean higher education institutions during the Covid-19 pandemic. A cluster analysis revealed three distinct manager types: "Elders" (oldest participants, almost equally distributed across positions, with least frequent EMIS access, moderate EMIS acceptance, and highest QM perceptions), "Mediators" (in operational and middle-management positions, with moderately frequent access to EMIS, and lowest EMIS acceptance and QM perceptions), and "Working Bees" (younger females in operational positions, with most frequent EMIS access, highest EMIS acceptance, and moderate QM perceptions). Knowledge of these profiles may enable customized training in the recovery after the Covid-19 pandemic.

Monitoring progress of maternal and neonatal immunization in Latin America and the Caribbean.

INTRODUCTION: The Americas committed to strengthening maternal and neonatal immunization (MNI) through the Pan American Health Organization (PAHO) Regional Immunization Action Plan (RIAP) 2016-20. We describe the progress toward RIAP MNI-related targets and those related to improvement of data quality and information systems; analyze national MNI policies and vaccination coverages; and identify enablers and challenges of monitoring and reporting MNI vaccination coverage in Latin America and the Caribbean (LAC). METHODOLOGY: Descriptive study of national MNI policies, vaccination coverage, and information systems. Sources of information included PAHO-World Health Organization (WHO) / UNICEF Joint Reporting Forms on immunization (JRF) 2013-2019, and other reports. RESULTS: LAC has met two of three RIAP targets related to MNI (countries with universal hepatitis B birth dose introduction and elimination of maternal and neonatal tetanus) and is on track to meet the other (countries with vaccination of pregnant women). As of 2018, of the 49 countries and territories in LAC, 32 vaccinate pregnant women against influenza and 29 provide tetanus-containing vaccine. Twenty-five countries offer universal hepatitis B birth dose vaccine and 31 offer BCG vaccine. In 2018, regional influenza vaccine coverage among pregnant woman was 75%. Regional coverages for BCG and hepatitis B birth dose (<24 h) vaccines were 93% and 79%, respectively. Countries have exceeded RIAP targets related to the quality of vaccination coverage data and the establishment of electronic immunization registries (EIRs). Challenges in monitoring MNI coverage include estimation of denominators and difficulties disaggregating data by group (e.g., pregnant women versus other groups). CONCLUSION: Despite progress in improving MNI in LAC, countries must further strengthen immunization monitoring systems and data quality to better report vaccination coverage among pregnant women and newborns. EIR and MNI information systems must be integrated, such that countries can use accurate data to design more timely and effective vaccination strategies.

[Toxoplasma gondii IgG seroprevalence in children with cancer from National Children's Antineoplastic Drug Program network in the Metropolitan Region, Chile: a multicenter study]. / Estudio multicéntrico, de seroprevalencia de IgG Toxoplasma gondii en niños con cáncer de la red del Programa Infantil Nacional de Drogas Antineoplásicas en la Región Metropolitana, Chile.

BACKGROUND: Toxoplasma gondii is a protozoan that affects a third of the world population and whose updated seroprevalence in children with cancer in our environment is unknown. AIM: To describe the seroprevalence of IgG anti-T. gondii in pediatric population with cancer treated in hospitals of the Metropolitan Region, Chile. METHOD: Cross-sectional study of the population of pediatric cancer patients treated in Santiago city, A serum sample was taken from 100 patients between June 2016 and May 2019. ELISA IgG T. gondii was performed. RESULTS: Of 100 children, 51% male. 12 were positive (12%), 84 negative (84%) and 4 indeterminate (4%). The stratification by age showed 43% patients between 0-5 years, 29% between 6-10 years, 20% in the group of 11-15 years and 8% in patients > 15 years. Sixty one percent of the samples came from patients with acute leukemia. The percentage of women who tested positive for IgG was 21% compared to 4% in men (P < 0.0011). CONCLUSION: 84% of children undergoing cancer treatment are seronegative for T. gondii, so it is important to educate on the prevention of the acquisition of this parasite in this population, due to the risk of developing serious and fatal disease.

Anxiety, Low Self-Esteem and a Low Happiness Index Are Associated with Poor School Performance in Chilean Adolescents: A Cross-Sectional Analysis.

OBJECTIVE: To analyze the relationship between anxiety, self-esteem, happiness index and primary school students' academic performance in Chilean adolescents from the Biobío province. METHODOLOGY: 733 (46.1% girls; 12 (1.3 years)) public primary school students that completed the 2018 Health and School Performance Survey carried out in the Biobío province were included in this cross-sectional analysis. The BECK Anxiety Inventory (BAI) was used to measure anxiety while happiness index and self-esteem were measured using the subjective happiness scale and the Rosenberg self-esteem scale, respectively. School performance was measured by grade point average (GPA) of language, math, physical education and cumulative GPA, and behavior associated with cognition in the school context was also considered. The relationship between mental health indicators and school performance was investigated using a one-way ANOVA and Pearson correlation. RESULTS: In comparison to students with low anxiety levels and high self-esteem and happiness levels, students with higher anxiety levels, lower self-esteem and happiness levels perceived themselves as having memory problems. They were also slower to solve math problems, had a shorter attention span in class and presented more difficulties in solving complex tasks, as well as being more nervous during testing. These students also got the lowest grade point average in math, language and physical education. CONCLUSIONS: High anxiety levels, low self-esteem and low happiness levels were associated with lower school performance and weaker behavior associated with cognition in Chilean adolescents. Implementing plans of emotional education and mental health could improve academic achievement.

Formation in Interprofessional Education in Nursing and Medical Students Globally. Scoping review.

OBJECTIVES: This work sought to know the state of the art related to the theme of Interprofessional Education (IPE) in the training of Nursing and Medical students and the level of evidence developed thus far. METHODS: This was an exploratory systematic review, declared as scoping review by the Joanna Briggs Institute, JBI, in which a search was performed in Embase, Science direct, Pubmed-Medline, Academic search complete, BVS, Scopus and ERIC databases, limiting between 2009 - 2019 by using the DeCS and MeSH terms of Interprofessional education, education research, healthcare professionals, nursing and medicine, selecting 39 original articles after carrying out the review process with the criteria by the JBI. RESULTS: Four thematic nuclei emerged: Experiences and perceptions of interprofessional learning, Didactics related with IPE, Empirical indicators related with IPE, and Development of professional skills. The highest level of evidence is presented by the articles dealing with didactics; on the contrary, no articles were found that dealt with topics related with early inclusion of IPE in the medical and nursing curricula, which are currently necessary to complement the focus of patient-centered care. CONCLUSIONS: The thematic nuclei show that the level of evidence in the literature is varied, although mostly descriptive in scope, highlighting the development of professional skills as a result of interprofessional education.

[Humoral immune response induced by influenza vaccine in children with acute lymphoblastic leukemia]. / Respuesta inmune humoral inducida por la vacuna influenza en niños con diagnóstico de leucemia linfoblástica aguda.

BACKGROUND: Patients with acute lymphoblastic leukemia (ALL) have high risk of severe influenza infection and vaccination is highly recommended. The immunogenicity and effectiveness of vaccination are lower than in healthy people. AIM: To evaluate the immune response induced by influenza vaccine in children with ALL and observe effectiveness. METHOD: Children with ALL in maintenance phase and healthy children were recruited. Blood samples were taken at vaccination day (D0) and at day 28 (D28). Humoral response was evaluated by hemaglutination inhibition test (HAI) against H1N1. Patients were followed up for one year, clinical data and influenza episodes were recorded. RESULTS: 34 children with ALL and 9 healthy children were included. Concerning HAI on D28, 12/34 patients and 5/8 healthy children had titers ≥ 1/40, with seroprotection rates of 35 and 63% respectively. Seroprotected children were older than non-seroprotected ones. During follow-up, only 3 patients non seroprotected, presented influenza infection, without oxygen supplementation or critical care support. DISCUSSION: Children with ALL had a lower seroprotection rate than healthy children. Nevertheless, none of the seroprotected children presented influenza infection, reinforcing the annual vaccination recommendation.

Cord blood banking: a historical perspective.

Umbilical cord blood (UCB) contains stem and progenitor cells capable of restoring haematopoietic and immunological function in vivo. UCB is currently used as an alternative source of haematopoietic stem cells for transplantation in patients suffering from haematological malignancies, bone marrow failures and inherited metabolic disorders. In order to facilitate transplantation, large repositories of frozen cord blood units (CBUs) from altruistic donations have been established in many parts of the world and to date there are more than 300,000 units stored worldwide. These products have been banked under stringent quality conditions, in order to ensure their safety and efficacy. The development and evolution of the policies and procedures currently in use in cord blood banking have been largely influenced by the clinical results of cord blood transplantation. This review aims to provide a historical overview of the various developments in the field of cord blood banking from its inception, highlighting the relevant aspects in their collection, banking and release that are known to influence the clinical outcome of these transplants.

Simulación interprofesional en estudiantes de enfermería y medicina, experiencias de sus protagonistas / Interprofessional Simulation with Nursing and Medical Students: The Protagonists' Experiences

Introducción: El impacto que ha tenido la implementación y avance de la educación interprofesional en las ciencias de la salud, ha demostrado que, articulado a diferentes estrategias didácticas, como la simulación clínica estandarizada, optimiza el aprendizaje colaborativo y el trabajo en equipo. Objetivo: Comprender los significados que estudiantes de enfermería y medicina le otorgaron a la educación interprofesional, desarrollada a través de simulación clínica estandarizada. Métodos: Estudio cualitativo interpretativo, donde a través de una determinación a priori basadas en criterios, se seleccionaron 40 estudiantes de enfermería y medicina que participaron de cuatro casos dentro de simulación clínica estandarizada, durante el segundo semestre del año 2019. Estas interacciones fueron videograbadas y luego se realizaron grupos focales para indagar la experiencia que los estudiantes habían tenido en la actividad simulada. Se realizó análisis de contenido de los videos y los grupos focales hasta que no se encontraron nuevos códigos. Resultado: Emergieron tres categorías principales: 1) Identificar las habilidades relacionales necesarias para la atención, 2) Aprender a colaborar a través de la educación interprofesional y 3) Sensaciones implícitas dentro de la simulación interprofesional. Conclusiones: La experiencia y significado que los estudiantes de enfermería y medicina le otorgaron a esta didáctica interprofesional les ayudó a reconocer la reflexión como punto de partida para el aprendizaje significativo y a descubrir en el compañero saberes que podían nutrir su proceso de formación, así como impactarlos en el desarrollo de habilidades interpersonales importantes en la práctica y que aplicarán en su futuro profesional(AU)

Introduction: The impact of the implementation and advancement of interprofessional education in health sciences has shown that, in articulation with different didactic strategies (such as standardized clinical simulation), collaborative learning and teamwork are optimized. Objective: To understand the meanings that nursing and medical students gave to interprofessional education, developed through standardized clinical simulation. Methods: An interpretive qualitative study was conducted, by means of an a priori determination based on criteria; 40 nursing and medical students were selected to participate in four cases within standardized clinical simulation, during the second semester of 2019. These interactions were recorded and focus groups were then held to delve into the students' experience of the simulated activity. Content analysis was applied to the videos and focus groups until new codes were found. Results: Three main categories emerged: 1) identifying relational skills needed for care, 2) Learning how to collaborate through interprofessional education, and 3) implicit feelings within interprofessional simulation. Conclusions: The experience and meaning that nursing and medical students gave to this interprofessional didactic resource helped them recognize thinking as a starting point for meaningful learning, as well as discover, in their partners, knowledge that could nurture their training process and impact them in the development of important interpersonal skills in practice and that they will apply in their professional future(AU)

The use of eHealth with immunizations: An overview of systematic reviews.

BACKGROUND: eHealth interventions may help increase vaccination uptake and health literacy related to immunization and improve immunization program efficiency. OBJECTIVES: To see where and how eHealth technologies have had a positive impact on immunization practices-using eHealth strategies to increase vaccination uptake, improve immunization program efficiency and advance heath literacy related to immunizations. METHODS: An overview of systematic reviews was conducted, searching PubMed, Scopus, Embase, and Web of Science for systematic reviews published through August 2017 for eHealth and immunizations (using pre-determined concepts for each). Two independent reviewers selected studies based on a priori criteria; disagreement was resolved by consensus. The quality of the included studies was evaluated using the Measurement Tool to Assess Systematic Reviews (AMSTAR). RESULTS: The primary search identified 198 results. After eliminating duplicates 158 remained. Upon applying the a priori set criteria to these, six articles were left to analyze. Four articles showed a positive relationship (a demonstrated benefit, improvement, increase in vaccination uptake, etc. when using eHealth technologies for immunization), one showed a promising relation / with potential, and one showed unknown effects as it focused on the difficulty of analyzing cost-benefits of immunization information systems (IIS). CONCLUSION: The review leads to a recommendation of using eHealth technologies to encourage immunizations and increase vaccination adherence and uptake and to continue assessing and documenting the use of eHealth for immunization.

Improving immunization data quality in Peru and Mexico: Two case studies highlighting challenges and lessons learned.

INTRODUCTION: The Global Vaccine Action Plan and the Regional Immunization Action Plan of the Americas call for countries to improve immunization data quality. Immunization information systems, particularly electronic immunization registries (EIRs), can help to facilitate program management and increase coverage. However, little is known about efforts to develop and implement such systems in low- and middle-income countries. We present the experiences of Mexico and Peru in implementing EIRs. METHODS: We conducted case studies of an EIR in Mexico and of a population registry in Peru. Information was gathered from technical documents, stakeholder focus groups, site visits, and semi-structured interviews of national stakeholders. We organized findings into narratives that emphasized challenges and lessons learned. RESULTS: Mexico built one of the world's first EIRs, incorporating novel features such as local-level tracking of patients; however, insufficient resources and poor data registration practices led to the system's discontinuation. Peru created an information system to improve affiliation to social programs, including the immunization program and quality of demographic data. Mexico's experience highlights lessons in failed sustainability of an EIR and a laudable effort to reform a country's information system. Peru's demonstrates that attempts to improve health and other data may strengthen health systems, including immunization data. Major challenges in information system implementation and sustainability in Peru and Mexico related to funding, clear governance structures, and resistance among health workers. DISCUSSION: These case studies reinforce the need for countries to ensure adequate funding, plans for sustainability, and health worker capacity-building activities before implementing EIRs. They also suggest new approaches to implementation, including economic incentives for sub-national administrative levels and opportunities to link efforts to improve immunization data with other health and political priorities. More information on best practices is needed to ensure the successful adoption and sustainability of immunization registries in low- and middle-income countries.

NADPH Oxidase Isoform 2 (NOX2) Is Involved in Drug Addiction Vulnerability in Progeny Developmentally Exposed to Ethanol.

Ethanol exposure increases oxidative stress in developing organs, including the brain. Antioxidant treatment during maternal ethanol ingestion improves behavioral deficits in rodent models of fetal alcohol spectrum disorder (FASD). However, the impact of general antioxidant treatment in their adult offspring and the Specific Reactive Species (ROS)-dependent mechanism, are not fully understood. We hypothesized that pre and early postnatal ethanol exposure (PEE) modifies redox homeostasis, in particular NOX2 function during reward signaling in the mesocorticolimbic pathway, which reinforces the effects of alcohol. We developed a FASD rat model which was evaluated during adolescence (P21) and adulthood (P70). We first studied whether redox homeostasis is affected in PEE animals, by analyzing mRNA expression of SOD1, CAT, and Gpx1. We found that PEE reduced the mRNA levels of these three anti-oxidant enzymes in PFC and HIPP at P21 and in the VTA at P70. We also analyzed basal mRNA and protein expression of NOX2 subunits such as gp91phox, p22 phox, and p47 phox, in mesocorticolimbic brain areas of PEE rat brains. At P21, gp91 phox, and p47 phox levels in the VTA were decreased. At P70, gp91 phox mRNA levels was decreased in HIPP and both mRNA and protein levels were decreased in PFC. Since NOX2 is regulated by the N-methyl-D-aspartate Receptor (NMDAR), we analyzed NMDAR mRNA expression and found differential expression of NMDAR subunits (NR1 and NR2B) in the PFC that was age dependent, with levels decreased at P21 and increased at P70. The analysis also revealed decreased NR2B mRNA expression in HIPP and VTA at P70. Offspring from maternal ethanol users consumed 25% more ethanol in a free choice alcohol consumption test than control rats, and showed place preference for an alcohol-paired compartment. In vivo inhibition of NOX2 using apocynin in drinking water, or infusion of blocked peptide gp91 phox ds in the VTA normalized alcohol place preference, suggesting that NOX2 plays an important role in addictive like behavior. Taken together, PEE significantly affects the expression of antioxidant enzymes, NOX2, NMDAR in an age, and brain region dependent manner. Moreover, we demonstrate that NOX2 regulates alcohol seeking behavior.