Relatório sobre avaliação da intervenção d suplementação com vitamina A nos cuidades de saude primarios nas provincias de sofala, manica,tete, zambezia e nampula / Report on the evaluation of the vitamin A supplementation intervention in primary health care in the provinces of sofala, manica, tete, zambezia and nampula

A deficiência de vitamina A (DVA) é um problema de grande interesse em saúde pública, visto que, afecta em todo o mundo, aproximadamente 19 milhões de mulheres grávidas e 190 milhões de crianças em idade pré-escolar, sendo a maioria nas regiões da África e Sudoeste da Ásia (OMS, 2013). Globalmente, estima-se que cerca de 30% das crianças menores de 5 anos de idade sofrem de deficiência de vitamina A, e dois porcentos de todas as mortes em menores de 5 anos de idade são atribuíveis à DVA (Stevens, 2015). Em Moçambique, a deficiência de micronutrientes tais como vitamina A é muito comum e possui alta prevalência em crianças menores de 5 anos e nas suas mães. Um estudo à escala nacional realizado em 2002, mostrou que 69% de crianças menores de 5 anos tinham deficiência de vitamina A (MISAU,2009). Esta condição pode levar a implicações moderadas a graves no sistema visual, tais como: cegueira noturna, xerose conjuntival, mancha de Bitot, xerose corneal, ulceração corneana, queratomalácia e xeroftalmicus (Sarni, Mattos, et al., 2007). Para além disso, consideram-se também como sendo problemas resultantes da DVA: a anemia, a má-resistência a infecções, o elevado risco de doenças e mortes resultantes de infecções na infância, como sarampo e outras doenças causadoras de diarreia (OMS, 2013). A suplementação com vitamina A é actualmente uma das intervenções mais amplamente utilizadas na provisão de vitamina A (Stevens, 2015). Evidências mostram que quando crianças menores de cinco anos são sistematicamente suplementadas com vitamina A pelo menos duas vezes por ano, existe uma contribuição na redução da taxa de mortalidade que varia de 24% a 30% (MISAU, 2018; Beaton et al., 1994). Actualmente, mais de 80 países em todo o mundo, estão a implementar programas de suplementação com vitamina A direccionados a crianças de 6-59 meses de idade (Stevens, 2015). Entre os anos 2003 e 2008, a cobertura de suplementação com vitamina A em Moçambique (uma dose nos últimos seis meses) aumentou consideravelmente de 50% a 72% (MISAU, 2009). O Inquérito Demográfico de Saúde de 2011 indica que a cobertura da suplementação com vitamina A em crianças dos 6 aos 59 meses foi de 78.4% em Nampula, 57.6% na Zambézia, 78.8% em Tete, 91.6% em Manica e 78.7% em Sofala. Verificou-se ainda que cerca de 68% das crianças não escolarizadas foram suplementadas com vitamina A, comparado com 89% das crianças com escolaridade de nível secundário ou mais; sessenta e cinco porcento das crianças no quintil de riqueza mais baixo receberam a suplementação com vitamina A comparado com 90% das crianças no quintil mais elevado (IDS, 2011). Em 1999, a suplementação com vitamina A (SVA) foi inicialmente introduzida em Moçambique através dos Dias Nacionais de Imunização. Em 2002, Moçambique reportou que 69% de crianças menores de 5 anos tinham deficiência de vitamina A. Em 2003, com base nos resultados deste estudo e, reconhecendo a importância da vitamina A na saúde das crianças, sobretudo nos primeiros anos de vida, o Ministério da Saúde em Moçambique introduziu a distribuição de cápsulas de vitamina A através dos serviços de saúde de rotina, à todas as crianças dos 6-59 meses, atingindo taxas de cobertura entre 40 e 60 por cento a nível naciona

Measles.

Measles is a highly contagious, potentially fatal, but vaccine-preventable disease caused by measles virus. Symptoms include fever, maculopapular rash, and at least one of cough, coryza, or conjunctivitis, although vaccinated individuals can have milder or even no symptoms. Laboratory diagnosis relies largely on the detection of specific IgM antibodies in serum, dried blood spots, or oral fluid, or the detection of viral RNA in throat or nasopharyngeal swabs, urine, or oral fluid. Complications can affect many organs and often include otitis media, laryngotracheobronchitis, pneumonia, stomatitis, and diarrhoea. Neurological complications are uncommon but serious, and can occur during or soon after the acute disease (eg, acute disseminated encephalomyelitis) or months or even years later (eg, measles inclusion body encephalitis and subacute sclerosing panencephalitis). Patient management mainly involves supportive therapy, such as vitamin A supplementation, monitoring for and treatment of secondary bacterial infections with antibiotics, and rehydration in the case of severe diarrhoea. There is no specific antiviral therapy for the treatment of measles, and disease control largely depends on prevention. However, despite the availability of a safe and effective vaccine, measles is still endemic in many countries and causes considerable morbidity and mortality, especially among children in resource-poor settings. The low case numbers reported in 2020, after a worldwide resurgence of measles between 2017 and 2019, have to be interpreted cautiously, owing to the effect of the COVID-19 pandemic on disease surveillance. Disrupted vaccination activities during the pandemic increase the potential for another resurgence of measles in the near future, and effective, timely catch-up vaccination campaigns, strong commitment and leadership, and sufficient resources will be required to mitigate this threat.

A systematic review of BCG vaccination policies among high-risk groups in low TB-burden countries: implications for vaccination strategy in Canadian indigenous communities.

BACKGROUND: Bacille Calmette-Guérin (BCG) vaccination against tuberculosis (TB) is widespread in high-TB-burden countries, however, BCG vaccination policies in low-burden countries vary. Considering the uncertainties surrounding BCG efficacy and the lower likelihood of TB exposure in low-incidence countries, most have discontinued mass vaccination, choosing instead a targeted vaccination strategy among high-risk groups. Given the increased risk of TB infection in Canadian Indigenous communities compared to the general Canadian population, these communities are a pertinent example of high-incidence groups in an otherwise low-burden country, warranting particular consideration regarding BCG vaccination strategy. This systematic review aims to synthesise and critically appraise the literature on BCG vaccination strategies in high-risk groups in low-incidence settings to provide policy considerations relevant to the Canadian Indigenous context. METHODS: A literature search of the Medline and Embase databases was conducted, returning studies pertaining to BCG vaccine efficacy, TB incidence under specific vaccination policies, BCG-associated adverse events, and vaccination policy guidelines in low-burden countries. Study screening was tracked using the Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia), and data pertaining to the above points of interest were extracted. RESULTS: The final review included 49 studies, spanning 15 countries. Although almost all of these countries had implemented a form of mass or routine vaccination previously, 11 have since moved to targeted vaccination of selected risk groups, in most cases due to the low risk of infection among the general population and thus the high number of vaccinations needed to prevent one case in the context of low-incidence settings. Regarding identifying risk groups for targeted screening, community-based (rather than individual risk-factor-based) vaccination has been found to be beneficial in high-incidence communities within low-incidence countries, suggesting this approach may be beneficial in the Canadian Indigenous setting. CONCLUSIONS: Community-based vaccination of high-incidence communities may be beneficial in the Canadian Indigenous context, however, where BCG vaccination is implemented, delivery strategies and potential barriers to achieving adequate coverage in this setting should be considered. Where an existing vaccination program is discontinued, it is crucial that an effective TB surveillance system is in place, and that case-finding, screening, and diagnostic efforts are strengthened in order to ensure adequate TB control. This is particularly relevant in Canadian Indigenous and other remote or under-served communities, where barriers to surveillance, screening, and diagnosis persist.

Geographical variation in the association of child, maternal and household health interventions with under-five mortality in Burkina Faso.

BACKGROUND: Over the past 15 years, scaling up of cost effective interventions resulted in a remarkable decline of under-five mortality rates (U5MR) in sub-Saharan Africa. However, the reduction shows considerable heterogeneity. We estimated the association of child, maternal, and household interventions with U5MR in Burkina Faso at national and subnational levels and identified the regions with least effective interventions. METHODS: Data on health-related interventions and U5MR were extracted from the Burkina Faso Demographic and Health Survey (DHS) 2010. Bayesian geostatistical proportional hazards models with a Weibull baseline hazard were fitted on the mortality outcome. Spatially varying coefficients were considered to assess the geographical variation in the association of the health interventions with U5MR. The analyses were adjusted for child, maternal, and household characteristics, as well as climatic and environmental factors. FINDINGS: The average U5MR was as high as 128 per 1000 ranging from 81 (region of Centre-Est) to 223 (region of Sahel). At national level, DPT3 immunization and baby post-natal check within 24 hours after birth had the most important association with U5MR (hazard rates ratio (HRR) = 0.89, 95% Bayesian credible interval (BCI): 0.86-0.98 and HRR = 0.89, 95% BCI: 0.86-0.92, respectively). At sub-national level, the most effective interventions are the skilled birth attendance, and improved drinking water, followed by baby post-natal check within 24 hours after birth, vitamin A supplementation, antenatal care visit and all-antigens immunization (including BCG, Polio3, DPT3, and measles immunization). Centre-Est, Sahel, and Sud-Ouest were the regions with the highest number of effective interventions. There was no intervention that had a statistically important association with child survival in the region of Hauts Bassins. INTERPRETATION: The geographical variation in the magnitude and statistical importance of the association between health interventions and U5MR raises the need to deliver and reinforce health interventions at a more granular level. Priority interventions are DPT3 immunization, skilled birth attendance, baby post-natal visits in the regions of Sud-Ouest, Sahel, and Hauts Bassins, respectively. Our methodology could be applied to other national surveys, as it allows an incisive, data-driven and specific decision-making approach to optimize the allocation of health interventions at subnational level.

Preventive care among primary care patients living with spinal cord injury.

Objective: Context/Objective: Family physicians may lack the knowledge or resources to adequately support patients with spinal cord injury (SCI). Our objectives were to determine patterns of preventive care for patients with SCI in a primary care setting (i.e. cancer screening, influenza vaccinations, general physicals, bone mineral density tests), and determine physicians' level of comfort with providing primary care to patients with SCI.Design: i) Retrospective chart review, ii) Survey of physicians in the family practice.Setting: Six primary care practice sites in Ontario, Canada.Participants: All adult rostered patients of the family practice with SCI; All family physicians in the six sites.Outcome Measures: Proportion of patients up-to-date on cancer screening, proportion of patients with influenza vaccinations, general physicals, bone mineral density tests; physicians' level of comfort with providing care to patients with SCI.Results: Sixty patients were included in analyses. Rates of cancer screening were generally poor. The highest uptake was seen for cervical cancer screening, where 50% of eligible women were up-to-date on Pap tests. Only 36.7% of patients were up-to-date on colorectal cancer screening. Only 14 (23.3%) patients had a documented general physical exam in their electronic record. There was a recorded flu vaccination for 55% of patients, and of those, there was a median of 19 months since last vaccination. Fifteen physicians (21.4%) responded to the survey. Ten physicians reported at least one patient with SCI, with the maximum being 20 patients. Comfort level in managing SCI-relevant conditions varied and was lowest for spasticity, respiratory issues and autonomic dysreflexia, where only 27.3% of respondents had some level of comfort.Conclusion There are many opportunities to improve the preventive care of patients living with SCI.

The Czech Surveillance System for Invasive Pneumococcal Disease, 2008-2013: A Follow-Up Assessment and Sensitivity Estimation.

BACKGROUND: Invasive pneumococcal disease (IPD) is caused by Streptococcus pneumoniae and mostly presents as pneumonia, sepsis or meningitis. A notable portion of IPD cases is vaccine preventable and the pneumococcal conjugate vaccine (PCV) was introduced into the routine childhood immunization programs in many countries during the last decades. OBJECTIVES: Before PCV introduction in the Czech Republic in 2010, a national surveillance system for IPD was implemented in 2008 and further improved in 2011. In this study, we describe the new surveillance system for the first time and measure its sensitivity between 2010 and 2013 using the capture-recapture method. Furthermore, we describe the recent epidemiological trend of IPD, taking sensitivity estimates into account. RESULTS AND CONCLUSIONS: Between 2010 and 2013 the estimated sensitivity of the overall IPD surveillance increased from 81% to 99%. The sensitivity of individual reporting sources increased from 72% to 87% for the laboratory system and from 31% to 89% for the epidemiological notification system. Crucial for this improvement was the introduction of quarterly report reminders in 2011. Due to positive source dependency, the presented sensitivity estimates are most probably overestimated and reflect the upper limit of reporting completeness. Stratification showed variation in sensitivity of reporting particularly according to region. An effect of the PVC vaccination in the Czech Republic is visible in the incidence of IPD in target age groups (<5 y). This influence was not evident in the total IPD incidence and may interfere with increasing sensitivity of reporting. In 2013, an increase in the IPD incidence was observed. This finding requires further observation and a detailed vaccine impact analysis is needed to assess the current immunization strategy.

Influenza vaccination and associated factors among Korean cancer survivors : a cross-sectional analysis of the Fourth & Fifth Korea National Health and Nutrition Examination Surveys.

Influenza vaccination is important for cancer survivors, a population with impaired immunity. This study was designed to assess influenza vaccination patterns among Korean cancer survivors. In this cross-sectional analysis, data were obtained from standardized questionnaires from 943 cancer survivors and 41,233 non-cancer survivors who participated in the Fourth and Fifth Korea National Health and Nutrition Examination Surveys (2007-2011). We identified the adjusted influenza vaccination rates and assessed factors associated with influenza vaccination using multivariate logistic regression. Cancer survivors tended to have a higher adjusted influenza vaccination rate than the general population. The rates for influenza vaccination in specific cancer types such as stomach, hepatic, colon, and lung cancers were significantly higher than non-cancer survivors. Among all cancer survivors, those with chronic diseases, elderly subjects, and rural dwellers were more likely to receive influenza vaccination; those with cervical cancer were less likely to receive influenza vaccination. Cancer survivors were more likely to receive influenza vaccinations than non-cancer survivors, but this was not true for particular groups, especially younger cancer survivors. Cancer survivors represent a sharply growing population; therefore, immunization against influenza among cancer survivors should be concerned as their significant preventative healthcare services.

Evaluating Washington State's immunization information system as a research tool.

OBJECTIVE: Immunization information systems (IISs) are powerful public health tools for vaccination activities. To date, however, their use for public health research has been limited, in part as a result of insufficient understanding on accuracy and quality of IIS data. We evaluated the completeness and accuracy of Washington State IIS (WAIIS) data, with particular attention to data elements of research interest. METHODS: We analyzed all WAIIS records on all children born between 2006 and 2010 with at least 1 vaccination recorded in WAIIS between 2006 and 2010. We assessed all variables for completeness and tested selected variables for internal validity. To assess external validity, we matched WAIIS data to records from Group Health, a large integrated health care organization in Washington State. On these children, we compared vaccination data in WAIIS with vaccination data from Group Health's immunization registry. RESULTS: The WAIIS data included 486,265 children and 8,670,234 unique vaccinations. Variables required by WAIIS (such as date of vaccination) were highly complete, but optional variables were often missing. For example, most records were missing data on route (80.7%) and anatomic site (81.7%) of vaccination. WAIIS data, when complete, were highly accurate relative to the Group Health immunization registry, with 96% to 99% agreement between fields such as vaccination code and anatomic site. CONCLUSIONS: Required data elements in WAIIS are highly complete and have both internal and external validity, suggesting that these variables are useful for research. Research requiring nonrequired variables should use additional validity checks before proceeding.

Influenza Vaccination and Associated Factors among Korean Cancer Survivors : A Cross-Sectional Analysis of the Fourth & Fifth Korea National Health and Nutrition Examination Surveys

Influenza vaccination is important for cancer survivors, a population with impaired immunity. This study was designed to assess influenza vaccination patterns among Korean cancer survivors. In this cross-sectional analysis, data were obtained from standardized questionnaires from 943 cancer survivors and 41,233 non-cancer survivors who participated in the Fourth and Fifth Korea National Health and Nutrition Examination Surveys (2007-2011). We identified the adjusted influenza vaccination rates and assessed factors associated with influenza vaccination using multivariate logistic regression. Cancer survivors tended to have a higher adjusted influenza vaccination rate than the general population. The rates for influenza vaccination in specific cancer types such as stomach, hepatic, colon, and lung cancers were significantly higher than non-cancer survivors. Among all cancer survivors, those with chronic diseases, elderly subjects, and rural dwellers were more likely to receive influenza vaccination; those with cervical cancer were less likely to receive influenza vaccination. Cancer survivors were more likely to receive influenza vaccinations than non-cancer survivors, but this was not true for particular groups, especially younger cancer survivors. Cancer survivors represent a sharply growing population; therefore, immunization against influenza among cancer survivors should be concerned as their significant preventative healthcare services.

Improved equity in measles vaccination from integrating insecticide-treated bednets in a vaccination campaign, Madagascar.

OBJECTIVE: To evaluate the effect of integrating ITN distribution on measles vaccination campaign coverage in Madagascar. METHODS: Nationwide cross-sectional survey to estimate measles vaccination coverage, nationally, and in districts with and without ITN integration. To evaluate the effect of ITN integration, propensity score matching was used to create comparable samples in ITN and non-ITN districts. Relative risks (RR) and 95% confidence intervals (CI) were estimated via log-binomial models. Equity ratios, defined as the coverage ratio between the lowest and highest household wealth quintile (Q), were used to assess equity in measles vaccination coverage. RESULTS: National measles vaccination coverage during the campaign was 66.9% (95% CI 63.0-70.7). Among the propensity score subset, vaccination campaign coverage was higher in ITN districts (70.8%) than non-ITN districts (59.1%) (RR=1.3, 95% CI 1.1-1.6). Among children in the poorest wealth quintile, vaccination coverage was higher in ITN than in non-ITN districts (Q1; RR=2.4, 95% CI 1.2-4.8) and equity for measles vaccination was greater in ITN districts (equity ratio=1.0, 95% CI 0.8-1.3) than in non-ITN districts (equity ratio=0.4, 95% CI 0.2-0.8). CONCLUSION: Integration of ITN distribution with a vaccination campaign might improve measles vaccination coverage among the poor, thus providing protection for the most vulnerable and difficult to reach children.

An adequacy evaluation of a 10-year, four-country nutrition and health programme.

BACKGROUND: Evaluations of large-scale health and nutrition programmes in developing countries are needed for determining the effectiveness of interventions. This article critically analyses a non-governmental organization (NGO)-led large-scale, multi-country, 10-year micronutrient and health (MICAH) programme with an 'adequacy evaluation', that is, a documentation of time trends in the expected direction. METHODS: MICAH was implemented from 1996 to 2005 in selected areas of Ethiopia, Ghana, Malawi and Tanzania, reaching >6 million people with numerous health and nutrition interventions. Coverage and impact were monitored through surveys at baseline, midpoint and end of funding. The data were subjected to post-hoc methods of quality determination, and, if of suitable quality, included in the adequacy evaluation. RESULTS: Most collected data were of moderate or high quality and therefore included in the adequacy evaluation. There were moderate to large improvements in vitamin A status in Ethiopian school-age children, children <5 years of age in Tanzania and Ghana and mothers in Ghana. Iodine status improved in Malawi and Tanzania. Anaemia rates and malaria prevalence decreased in women, pregnant women and pre-school children in Ghana, Malawi and Tanzania, but anaemia increased in Ethiopian women. Large increases were reported for rates of exclusive breastfeeding and immunization. Child growth improved to the maximum that would be predicted with the given interventions. CONCLUSIONS: Numerous nutrition and health impacts were observed in the intervention areas, often of a magnitude equal to or larger than observed in controlled interventions or trials. These results show the value of integrated long-term interventions.

[Risk factors for delayed or missed measles vaccination in young children]. / Risikofaktoren für eine verspätete oder nicht erfolgte Masernimpfung bei Kleinkindern.

Because of low measles vaccine coverage rates, measles outbreaks have been observed several times during recent years in Germany. The aim of this study is to identify parents' attitudes and beliefs towards immunisations and socio-economic factors which are associated with delayed or missed first measles vaccination in young children. We used data from a representative German-wide immunisation survey on 2116 children born between 1 January 2002 and December 2004 by collecting precise vaccination information from vaccination cards. The influence of socio-economic determinants and parental attitudes towards immunisations on the timing of the first measles dose was analysed by using multivariable Cox regression. Of these children 46.8% (95% CI: 44.5-49.1) received their first measles dose according to the recommendations of the standing committee on vaccination (STIKO) by month 15. In multivariable analysis, fathers aged 28-33 years and birth order as well as parents' belief in homeopathy and other parental attitudes indicating lack of knowledge about the importance of vaccinations significantly influenced an early immunisation. Not general opposition, but insufficient parental knowledge about the harmfulness of measles infection seemed to be responsible for the low measles vaccination rates.

Developing a "best practice" influenza vaccination program for health care workers--an evidence-based, leadership-modeled program.

Transmission of influenza among health care workers is a well-documented problem. Influenza vaccination is an effective intervention to reduce the influenza burden; however, vaccination rates remain low among health care workers. The challenge for occupational health nurses is how to increase health care workers' vaccination rates. This article describes the key components of a successful influenza program at a large integrated health care system. A multidisciplinary team developed and implemented an evidence-based, leadership-modeled program that led to improvement in health care workers' vaccination rates from 66% to 77% in year one and from 77% to 84% in year two.

A cost-effectiveness analysis of adding a human papillomavirus vaccine to the Australian National Cervical Cancer Screening Program.

BACKGROUND: The cost-effectiveness of adding a human papillomavirus (HPV) vaccine to the Australian National Cervical Screening Program compared to screening alone was examined. METHODS: A Markov model of the natural history of HPV infection that incorporates screening and vaccination was developed. A vaccine that prevents 100% of HPV 16/18-associated disease, with a lifetime duration of efficacy and 80% coverage offered through a school program to girls aged 12 years, in conjunction with current screening was compared with screening alone using cost (in Australian dollars) per life-year (LY) saved and quality-adjusted life-year (QALY) saved. Sensitivity analyses included determining the cost-effectiveness of offering a catch-up vaccination program to 14-26-year-olds and accounting for the benefits of herd immunity. RESULTS: Vaccination with screening compared with screening alone was associated with an incremental cost-effectiveness ratio (ICER) of $51 103 per LY and $18 735 per QALY, assuming a cost per vaccine dose of $115. Results were sensitive to assumptions about the duration of vaccine efficacy, including the need for a booster ($68 158 per LY and $24 988 per QALY) to produce lifetime immunity. Accounting for herd immunity resulted in a more attractive ICER ($36 343 per LY and $13 316 per QALY) for girls only. The cost per LY of vaccinating boys and girls was $92 052 and the cost per QALY was $33 644. The cost per LY of implementing a catch-up vaccination program ranged from $45 652 ($16 727 per QALY) for extending vaccination to 14-year-olds to $78 702 ($34 536 per QALY) for 26-year-olds. CONCLUSIONS: These results suggest that adding an HPV vaccine to Australia's current screening regimen is a potentially cost-effective way to reduce cervical cancer and the clinical interventions that are currently associated with its prevention via screening alone.

Implementation and evaluation of a nursing assessment/standing orders-based inpatient pneumococcal vaccination program.

BACKGROUND: Pneumococcal vaccination is recommended for patients aged 65 years and greater; inpatient vaccination has been suggested as means to increase vaccination rates is this population. Our hospital implemented an inpatient pneumococcal vaccination program, and expanded the population of interest to include patients aged 2 to 64 years with risk factors for pneumococcal bacteremia. We studied the outcomes of this program to determine if the rate of pneumococcal vaccination opportunities and pneumococcal vaccination rate could be significantly increased through the application of an in-hospital pneumococcal vaccination program, based on standing orders and assessment by Registered Nurses, when compared to our previous method of physician assessment and written vaccination order for each patient. METHODS: Subjects were inpatients admitted to non-intensive care units of our hospital from August to December of 2004. Cases were aged greater than 65 years, or were greater than 2 years of age with selected risk factors. Patients with previous pneumococcal vaccination with the past five years, in terminal or comfort care, those allergic to vaccine components, patients who received organ or bone marrow transplants in the year prior to the study, and those physicians barred them from the vaccination protocol were excluded. Program effectiveness was evaluated through retrospective evaluation of medical records to determine if subjects had been evaluated for vaccination eligibility, and if subjects were eligible, whether or not they had received pneumococcal vaccination. RESULTS: Overall vaccination opportunity rate after implementation of the standing orders-based program increased form 8.6% to 59.1%, and overall vaccination rates improved form 0% to 15.4%. The study found a statistically significant difference in the rate of pneumococcal vaccination opportunities (chi(2) = 182.46, p = .00) and the pneumococcal vaccination rate (chi(2) = 56, p = .00) between the two methods of assessment and vaccination; these results are attributable to the study intervention. CONCLUSIONS: The study program contributed to increased overall vaccination opportunity and vaccination rates, when compared to the previous method. The overall rates of vaccination attained by this program were often lower than those reported in the existing literature for other program designs; however, this may be due to an unusually high rate of vaccination refusal.

Financial requirements of immunisation programmes in developing countries: a 2004-2014 perspective.

Vaccines are a key contributor to public health, especially in developing countries. Despite numerous demonstrations of the cost-effectiveness of immunisation, vaccines spending accounted for only 1.7% of the total pharmaceutical market in 2002, when UNICEF estimated that 34 million children were not reached by routine immunisation, most of them in developing countries. Several international organizations or initiatives, like the Global Alliance for Vaccines and Immunisation (GAVI), have defined a long-term goal of universal immunisation in developing countries. There is an urgent need to estimate the financial resources required to meet this goal. The objective of this study was to anticipate the funding needs for childhood immunisation in developing countries over the 2004-2014 period. The study scope includes all the 75 countries eligible for support from GAVI, and covers existing vaccines that are considered as a priority for GAVI (DTP (diphtheria, tetanus, pertussis), hepatitis B, Haemophilus influenzae type b (as a stand alone presentation or in combination with DTP) and yellow fever) as well as future vaccines (meningitis A and C, rotavirus, human papilloma virus (HPV), malaria, Streptococcus pneumoniae and tuberculosis) likely to be available within the 10-year period. We developed a methodology to estimate the number of doses required, based on disease prevalence and incidence, target populations, introduction dates of new vaccines, coverage dynamics and dosing regimen. The introduction price and price evolution of vaccines over time were modelled, taking into account the type of vaccine, the expected return on investment from vaccine manufacturers and the competitive landscape. Non-vaccine costs (capital costs and non-vaccine recurrent costs) were estimated based on the number of people immunised and number of doses dispensed, using available case studies as a reference. According to the optimal scenario that would consider the provision of all vaccines to all relevant developing countries as soon as they are available, funding requirements to cover the associated total costs over the 10-year period were estimated to be about US$ 30 billion. Vaccines-related costs represent the largest share, with estimated costs of US$ 21 billion (among which 18 billion for new vaccines), the remaining needs being split between capital costs and other recurrent costs. Accounting for the main imponderables (such as delay in vaccines launch compared to industry plans) as well as probable phasing of vaccine introduction in countries, the total costs of immunisation would be reduced to US$ 14-17 billion over the same period. Vaccines-related costs represent the largest share (US$ 7.1-9.3 billion, among which 4.3-6.5 billion for new vaccines). This study advocates for the anticipation of the substantial financial resources needed to (a) purchase and introduce these vaccines in the developing countries in order to reduce the time lag between availability in industrialised and developing countries; and (b) stimulate vaccine researchers and manufacturers to continue research and development of much needed vaccines for the developing world.

[Alternative immunization schedule and combined vaccines in paediatric practice]. / Alternatywny program szczepien i szczepionki skojarzone w praktyce pediatrycznej.

European countries individually implement their national immunisation schedules adjusted to their economic situation, epidemiological risks and other socio-political factors. The polish schedule of compulsory vaccination includes an obligatory part financed by the state and the recommended one financed individually by parents of patients themselves. The officially registered multi component vaccines my become an alternative for the obligatory schedules. Benefits of combined vaccine comprise: reduced number injections per visit and reduced number of exposures to possible injection pain; less or no exposure to thiomersal; less time spent in doctor visit, less waste and increased injection safety with fewer syringes, reduced immunisation programme costs and facilitated addition data collection through easier documentation and simplified implementation of immunisation programmes.

Evaluation of the national immunisation programme in the Netherlands: immunity to diphtheria, tetanus, poliomyelitis, measles, mumps, rubella and Haemophilus influenzae type b.

The immunity to vaccine-preventable diseases included in the Dutch immunisation programme in the general population and among orthodox reformed individuals who refuse vaccination was assessed. The programme induces good protection. However, a large proportion of adults lacks diphtheria and tetanus immunity. Measles, mumps and rubella seroprevalence was somewhat lower among vaccinated compared to unvaccinated cohorts. The prevalence of HibPS antibodies declined during 2.5 years after the fourth vaccination. However, protection occurs also by memory immunity. Herd immunity is sufficient among the general population, but not among orthodox reformed individuals. Immunosurveillance is an efficient way to evaluate the effects of immunisation programmes and identify risk groups for infection.