Assessing the relationship between operationally defined zero-dose communities and access to selected primary healthcare services for children and pregnant women in emergency settings.

In this study the authors examine the relationship between "zero-dose" communities and access to healthcare services. This was done by first ensuring the first dose of the Diphtheria Tetanus and Pertussis vaccine was a better measure of zero-dose communities than the measles-containing vaccine. Once ensured, it was used to examine the association with access to primary healthcare services for children and pregnant women in the Democratic Republic of Congo, Afghanistan, and Bangladesh. These services were divided into: a) unscheduled healthcare services such as birth assistance as well as seeking care and treatment for diarrheal diseases and cough/fever episodes and b) other scheduled health services such as antenatal care visits and vitamin A supplementation. Using recent Demographic Health Survey data (2014: Democratic Republic of Congo, 2015: Afghanistan, 2018: Bangladesh), data was analyzed via Chi Squared analysis or Fischer's Exact Test. If significant, a linear regression analysis was performed to examine if the association was linear. While the linear relationship observed between children who had received the first dose of the Diphtheria Tetanus and Pertussis vaccine (the reverse to zero-dose communities) and coverage of other vaccines was expected, the results of the regression analysis depicted an unexpected split in behavior. For scheduled and birth assistance health services, a linear relationship was generally observed. For unscheduled services associated with illness treatments, this was not the case. While it does not appear that the first dose of the Diphtheria Tetanus and Pertussis vaccine can be used to predict (at least in a linear manner) access to some primary (particularly illness treatment) healthcare services in emergency/ humanitarian settings, it can serve as an indirect measure of health services not associated with the treatment of childhood infections such as antenatal care, skilled birth assistance, and to a lesser degree even vitamin A supplementation.

Prereferral rectal artesunate and referral completion among children with suspected severe malaria in the Democratic Republic of the Congo, Nigeria and Uganda.

INTRODUCTION: Children who receive prereferral rectal artesunate (RAS) require urgent referral to a health facility where appropriate treatment for severe malaria can be provided. However, the rapid improvement of a child's condition after RAS administration may influence a caregiver's decision to follow this recommendation. Currently, the evidence on the effect of RAS on referral completion is limited. METHODS: An observational study accompanied the roll-out of RAS in three malaria endemic settings in the Democratic Republic of the Congo (DRC), Nigeria and Uganda. Community health workers and primary health centres enrolled children under 5 years with suspected severe malaria before and after the roll-out of RAS. All children were followed up 28 days after enrolment to assess their treatment-seeking pathways. RESULTS: Referral completion was 67% (1408/2104) in DRC, 48% (287/600) in Nigeria and 58% (2170/3745) in Uganda. In DRC and Uganda, RAS users were less likely to complete referral than RAS non-users in the pre-roll-out phase (adjusted OR (aOR)=0.48, 95% CI 0.30 to 0.77 and aOR=0.72, 95% CI 0.58 to 0.88, respectively). Among children seeking care from a primary health centre in Nigeria, RAS users were less likely to complete referral compared with RAS non-users in the post-roll-out phase (aOR=0.18, 95% CI 0.05 to 0.71). In Uganda, among children who completed referral, RAS users were significantly more likely to complete referral on time than RAS non-users enrolled in the pre-roll-out phase (aOR=1.81, 95% CI 1.17 to 2.79). CONCLUSIONS: The findings of this study raise legitimate concerns that the roll-out of RAS may lead to lower referral completion in children who were administered prereferral RAS. To ensure that community-based programmes are effectively implemented, barriers to referral completion need to be addressed at all levels. Alternative effective treatment options should be provided to children unable to complete referral. TRIAL REGISTRSTION NUMBER: NCT03568344; ClinicalTrials.gov.