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

Cost-effectiveness analysis of 13-valent pneumococcal conjugate vaccine versus 23-valent pneumococcal polysaccharide vaccine in an adult population in South Korea.

In South Korea, the National Immunization Program offers a 23-valent pneumococcal polysaccharide vaccine (PPSV23) for the elderly; however, the 13-valent pneumococcal conjugate vaccine (PCV13) is not included, and vaccination is not offered to younger, at-risk populations. This study offers a comparative analysis of PCV13 and PPSV23 in Korea's adults, stratified by age and risk group. A Markov model with a lifetime horizon was developed from the healthcare perspective. Data sources included the Health Insurance Review & Assessment Service, Korea Centre for Disease Control & Prevention and Korean medical institutions. An expert panel tested data validity. The CAPiTA trial and Cochrane meta-analysis were used to obtain vaccine effectiveness data. Regardless of co-morbidity, when the sequential PCV13-PPSV23 strategy was compared to that using PPSV23-only, in elderly populations, the incremental cost-effectiveness ratio (ICER) was 3,300 USD per quality-adjusted life years (QALY). For the risk group aged ≥65 years, the ICER of the addition of PCV13 over the existing PPSV23-only strategy was 3,404 USD/QALY. However, on replacing PPSV23 with PCV13, for all elderly populations, an ICER of 1,421 USD/QALY resulted; for the risk group aged ≥65 years, the ICER was 1,736 USD/QALY. For the 18-64 year-old risk group, the sequential PCV13-PPSV23 strategy yielded an ICER of 3,629 USD/QALY over the PPSV23-only strategy, and 6,643 USD/QALY compared to no vaccination. Thus, the PCV13→PPSV23 combination strategy for elderly populations was found to be a cost-effective alternative to the current National Immunization Program regardless of co-morbidity. This finding was the same as that for younger, at-risk populations.

Late onset of injection site reactions after vaccination with the 13-valent pneumococcal conjugate vaccine in adult study populations.

Injection site reactions (ISRs; redness, swelling and pain) commonly occur within 1-2 days after vaccination. After administration of toxoid vaccines including diphtheria toxoid, a later onset of ISRs has also been observed. As the serotype capsular polysaccharides in the 13-valent pneumococcal conjugate vaccine (PCV13) are conjugated to cross-reactive material 197 (CRM197), a nontoxic variant of diphtheria toxin, the onset of ISRs over 14 days was explored in 8 adult studies with 19 cohorts. Subjects received PCV13 with aluminum phosphate (AlPO4, n = 5667) or without AlPO4 (n = 304); 1097 subjects received 23-valent pneumococcal polysaccharide vaccine (PPSV23). Late ISRs with onset between days 6-14 were observed in 8/8 cohorts aged ≥65 years after PCV13 with AlPO4 (incidence across cohorts for redness, 2.3%-19.6%; swelling, 0.9%-10.8%; pain, 1.6%-10.0%) and in 1/1 cohort after PCV13 without AlPO4 (redness 10.5%; swelling 7.5%; pain 12.3%); and in 2/4 cohorts aged 50 to 64 years after PCV13 (redness 3.1%-4.8%; swelling 1.0%-3.2%; pain 3.7%-5%). Late ISRs were not generally observed in 1/1 cohort aged 18 to 49 years after PCV13; in 2/2 cohorts aged ≥53 years after PCV13 revaccination; and in 3/3 cohorts aged ≥60 years who received PPSV23, which does not contain CRM197. Post hoc analysis demonstrated numerically higher pneumococcal immune responses in subgroups with late ISRs versus those without. In conclusion, causality of late ISRs is likely multifactorial, with age and the PCV13 carrier protein CRM197 potentially associated. AlPO4, a vaccine adjuvant, did not appear causally related. Observations do not affect the favorable risk-benefit profile of PCV13.

Cost-effectiveness of mass dog rabies vaccination strategies to reduce human health burden in Flores Island, Indonesia.

The cost-effectiveness of different mass dog rabies vaccination strategies, defined as the costs per year of life lost (YLL) averted was evaluated for a period of 10 years by means of a dynamic simulation study for a typical village on Flores Island. In the base strategy (no dog vaccination and no post-exposure treatment (PET) of human bite cases), the model showed that the introduction of the virus by one infectious dog into an isolated village with 1500 inhabitants and 400 dogs resulted in 881 YLLs during a 10-year simulation period, which is equivalent to 30 human rabies cases. An annual dog vaccination campaign with a coverage of 70% using a short-acting vaccine saved 832 YLLs, while the cumulative costs for the public sector were US$3646 or US$4.38 per YLL averted. Switching to a long-acting vaccine, the annual vaccination strategies with a coverage of 50% (AV_156_50) or 70% (AV_156_70) reduced the baseline YLLs from 881 to respectively 78 and 26 YLLs with cumulative costs of US$3716 and US$2264 or US$4.63 and US$2.65 per YLL averted, respectively. In general, dog vaccination was more cost-effective than PET alone (US$2.65-4.63 per YLL averted versus US$23.29 per YLL averted). Although a combination of PET with AV_156_70 was less cost-effective compared to AV_156_70 alone, this strategy was able to prevent all human deaths due to rabies. A combination of PET with annual vaccination using a short-acting vaccine at a coverage of 50% was far from being cost-effective, suggesting that the currently applied rabies control in Flores Island is not an efficient investment in reducing human rabies burden. An increased investment in either an increase in the current coverage or in a switch from the short-acting vaccine to the long-acting vaccine type would certainly pay off.

Cost-Effectiveness of Mass Dog Vaccination Campaigns against Rabies in Flores Island, Indonesia.

A dynamic deterministic simulation model was developed to determine the cost-effectiveness of different mass dog vaccination strategies against rabies in a dog population representative of a typical village on Flores Island. Cost-effectiveness was measured as public cost per averted dog-rabies case. Simulations started with the introduction of one infectious dog into a susceptible dog population of 399 dogs and subsequently ran for a period of 10 years. The base scenario represented a situation without any control intervention. Evaluated vaccination strategies were as follows: annual vaccination campaigns with short-acting vaccine (immunity duration of 52 weeks) (AV_52), annual campaigns with long-acting vaccine (immunity duration of 156 weeks) (AV_156), biannual campaigns with short-acting vaccine (BV_52) and once-in-2-years campaigns with long-acting vaccine (O2V_156). The effectiveness of the vaccination strategies was simulated for vaccination coverages of 50% and 70%. Cumulative results were reported for the 10-year simulation period. The base scenario resulted in three epidemic waves, with a total of 1274 dog-rabies cases. The public cost of applying AV_52 at a coverage of 50% was US$5342 for a village. This strategy was unfavourable compared to other strategies, as it was costly and ineffective in controlling the epidemic. The costs of AV_52 at a coverage of 70% and AV_156 at a coverage of 70% were, respectively, US$3646 and US$3716, equivalent to US$3.00 and US$3.17 per averted dog-rabies case. Increasing the coverage of AV_156 from 50% to 70% reduced the number of cases by 7% and reduced the cost by US$1452, resulting in a cost-effectiveness ratio of US$1.81 per averted dog-rabies case. This simulation model provides an effective tool to explore the public cost-effectiveness of mass dog vaccination strategies in Flores Island. Insights obtained from the simulation results are useful for animal health authorities to support decision-making in rabies-endemic areas, such as Flores Island.

Budget impact and cost-utility analysis of universal infant rotavirus vaccination in Spain.

Rotavirus is not included in the Spanish mass infant vaccination schedule but has also not been economically evaluated for its inclusion. We analysed cost-utility of the universal infant rotavirus vaccination using RotaTeq® versus no vaccination in Spain. We also carried out a budget impact analysis and determined the effect on results of different variables introduced in the model. A deterministic Markov model was built considering loss of quality of life for children and their parents, and introducing direct and indirect costs updated to 2011. The introduction of the vaccination using RotaTeq® as a universal infant vaccination would increase the annual health care budget in 10.43 million euro and would result in a gain of an additional Quality Adjusted Life Year at a cost of 280,338€ from the healthcare system perspective and 210,167€ from the societal perspective. The model was stable to variable modifications. To sum up, according to our model and estimates, the introduction of a universal infant rotavirus vaccination with RotaTeq® in Spain would cause a large impact on the health care budget and would not be efficient unless significant variations in vaccine price, vaccine efficacy and/or utilities took place.

Impact of supplemental immunisation activity (SIA) campaigns on health systems: findings from South Africa.

BACKGROUND: Supplemental immunisation activity (SIA) campaigns provide children with an additional dose of measles vaccine and deliver other child health interventions including vitamin A supplements, deworming medications and oral polio vaccines. They also require the mobilisation of a large health workforce. We assess the impact of the implementation of SIA campaigns on selected routine child and maternal health services in South Africa (SA). METHODS: We use district-level monthly headcount data for 52 South African districts for the period 2001-2010, sourced from the District Health Information System, SA. The data include 12 child and maternal health headcount indicators including routine immunisation, and maternal and reproductive health indicators. We analyse the association between the implementation of the 2010 SIA campaign and the change (decrease/increase) in headcounts, using a linear regression model. RESULTS: We find a significant decrease for eight indicators. The total number of fully immunised children before age 1 decreased by 29% (95% CI 23% to 35%, p<0.001) during the month of SIA implementation; contraceptive use and antenatal visits decreased by 7-17% (p ≤ 0.02) and about 10% (p<0.001), respectively. CONCLUSIONS: SIA campaigns may negatively impact health systems during the period of implementation by disrupting regular functioning and diverting resources from other activities, including routine child and maternal health services. SIA campaigns present multidimensional costs that need to be explicitly considered in benefit-cost assessments.

Risk perception, risk management and safety assessment: what can governments do to increase public confidence in their vaccine system?

For decades vaccine program managers and governments have devoted many resources to addressing public vaccine concerns, vaccine risk perception, risk management and safety assessment. Despite ever growing evidence that vaccines are safe and effective, public concerns continue. Education and evidence based scientific messages have not ended concerns. How can governments and programs more effectively address the public's vaccine concerns and increase confidence in the vaccine safety system? Vaccination hesitation has been attributed to concerns about vaccine safety, perceptions of high vaccine risks and low disease risk and consequences. Even when the public believes vaccines are important for protection many still have concerns about vaccine safety. This overview explores how heuristics affect public perception of vaccines and vaccine safety, how the public finds and uses vaccine information, and then proposes strategies for changes in the approach to vaccine safety communications. Facts and evidence confirming the safety of vaccines are not enough. Vaccine beliefs and behaviours must be shaped. This will require a shift in the what, when, how and why of vaccine risk and benefit communication content and practice. A change to a behavioural change strategy such as the WHO COMBI program that has been applied to disease eradication efforts is suggested.

El virus de la hepatitis B en niños recién inmigrados / Hepatitis B serology in immigrant children

Fundamento. La inmigración es importante en nuestro medio. Algunos protocolos de atención al niño inmigrante incluyen la determinación del estado serológico respecto al virus de la hepatitis B (VHB). Objetivo. Valorar la conveniencia de la determinación sistemática del antígeno de superficie (HBsAg), anticuerpo contra el core (HBSerologia del virus de l’hepatitis B en infants recentment immigrats Ana Estabanell 1, Rosa M. Masvidal 2, Elisa de Frutos 2, Dolors Riera 3, Cecilia Cruz 1, Beatriz Miguel 2 1 CAP Gòtic (annex Rull). ABS Gòtic. Institut Català de la Salut. Barcelona. 2 CAP Dr. Lluís Sayé. ABS Raval Nord. Institut Català de la Salut. Barcelona. 3 CAP Drassanes. ABS Raval Sud. Institut Municipal d’Assistència Sanitària de Barcelona. cAc), anticuerpo contra el Ag de superficie (HBsAc), en niños inmigrantes. Determinar la prevalencia del HBsAc positivo en los vacunados contra el VHB. Método. Se determinaron HbsAg, HBsAc, HBcAc en niños de 6 meses a 15 años procedentes de países de baja renta que habían llegado hacía menos de 12 meses. Se registró su estado vacunal. Se estimó la prevalencia y el intervalo de confianza del resultado. Resultados. De los 1.226 niños/as, se determinó el HbsAg en 1.098 (89,5%), siendo 8 positivos: 0,79% (intervalo de confianza (IC) 95%: 0,37-1,43), dos de éstos constaban como vacunados para el VHB. En 1.024 se determinó el HBcAc, siendo el único marcador positivo en 7 casos: 0,98% (IC 0,47-1,80); el HBsAc se determinó en 987 y fue positivo en el 33,23%. De los 333 niños vacunados con tres dosis, en 267 se determinó el HBsAc, siendo positivo en el 59,9% (IC 95%: 55,15-64,45). Conclusiones. Consideramos indicada la determinación del HbsAg a los niños inmigrantes, incluyendo los que aportan datos de vacunación del VHB completa. No creemos justificado solicitar el HBcAc de manera sistemática. En niños inmigrantes vacunados puede estar indicado determinar los HBsAc(AU)

Background. Immigration is an important phenomenon in our environment. Some guidelines for the care of the immigrant child include the evaluation of hepatitis B virus (HBV) serology. Objective. To evaluate the need for the systematic measurement of surface antigen (HBsAg), core antigen antibody (HBcAb), and surface antigen antibody (HBsAb) in young immigrants, and to determine the prevalence of HBsAb in those who receive HBV vaccination. Method. HBsAg, HBsAb, and HBcAb values were determined in children from 6 months to 15 years of age who emigrated from low-income countries within the prior 12 months. The prevalence and confidence intervals were calculated. Results. Of the 1,226 children evaluated, HBsAg was measured in 1,098 (89.5%) and was positive in 8 (0.79%, CI 0.37-1.43), including two cases in whom vaccination had been documented; HBcAb was measured in 1,024 and was the only positive HBV marker in 7 cases (0.98%, CI 0.47-1.80); and HBsAb was measured in 987 and was positive in 33.26%. In 30.8% of the children, the only positive marker was HBsAb. Of the 333 children Background. Immigration is an important phenomenon in our environment. Some guidelines for the care of the immigrant child include the evaluation of hepatitis B virus (HBV) serology. Objective. To evaluate the need for the systematic measurement of surface antigen (HBsAg), core antigen antibody (HBcAb), and surface antigen antibody (HBsAb) in young immigrants, and to determine the prevalence of HBsAb in those who receive HBV vaccination. Method. HBsAg, HBsAb, and HBcAb values were determined in children from 6 months to 15 years of age who emigrated from low-income countries within the prior 12 months. The prevalence and confidence intervals were calculated. Results. Of the 1,226 children evaluated, HBsAg was measured in 1,098 (89.5%) and was positive in 8 (0.79%, CI 0.37-1.43), including two cases in whom vaccination had been documented; HBcAb was measured in 1,024 and was the only positive HBV marker in 7 cases (0.98%, CI 0.47-1.80); and HBsAb was measured in 987 and was positive in 33.26%. In 30.8% of the children, the only positive marker was HBsAb. Of the 333 children(AU)

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.

Vitamin A supplementation and retinoic acid treatment in the regulation of antibody responses in vivo.

Vitamin A (VA, retinol) is essential for normal immune system maturation, but the effect of VA(1) on antibody production, the hallmark of successful vaccination, is still not well understood. In countries where VA deficiency is a public health problem, many children worldwide are now receiving VA along with immunizations against poliovirus, measles, diphtheria, pertussis, and tetanus. The primary goal has been to provide enough VA to protect against the development of VA deficiency for a period of 4-6 months. However, it is also possible that VA might promote the vaccine antibody response. Several community studies, generally of small size, have been conducted in children supplemented with VA at the time of immunization, as promoted by the World Health Organization/UNICEF. However, only a few studies have reported differences in antibody titers or seroconversion rates due to VA. However, VA status was not directly assessed, and in some communities children were often breast fed, another strategy for preventing VA deficiency. Some of the vaccines used induced a high rate of seroconversion, even without VA. In children likely to have been VA deficient, oral polio vaccine seroconversion rate was increased by VA. In animal models, where VA status was controlled and VA deficiency confirmed, the antibody response to T-cell-dependent (TD) and polysaccharide antigens was significantly reduced, congruent with other defects in innate and adaptive immunity. Moreover, the active metabolite of VA, retinoic acid (RA) can potentiate antibody production to TD antigens in normal adult and neonatal animals. We speculate that numerous animal studies have correctly identified VA deficiency as a risk factor for low antibody production. A lack of effect of VA in human studies could be due to a low rate of VA deficiency in the populations studied or low sample numbers. The ability to detect differences in antibody response may also depend on the vaccine-adjuvant combination used. Future studies of VA supplementation and immunization should include assessment of VA status and a sufficiently large sample size. It would also be worthwhile to test the effect of neonatal VA supplementation on the response to immunization given after 6 months to 1 year of age, as VA supplementation, by preventing the onset of VA deficiency, may improve the response to immunizations given later on.

Integrating insecticide-treated bednets into a measles vaccination campaign achieves high, rapid and equitable coverage with direct and voucher-based methods.

Population coverage of insecticide-treated nets (ITNs) in Africa falls well below the Abuja target of 60% while coverage levels achieved during vaccination campaigns in the same populations typically exceed 90%. Household (HH) cost of ITNs is an important barrier to their uptake. We investigated the coverage, equity and cost of linking distribution of free ITNs to a measles vaccination campaign. During a national measles vaccination campaign in Zambia, children in four rural districts were given a free ITN when they received their measles vaccination. In one urban district, children were given a voucher, which could be redeemed for a net at a commercial distribution site. About 1700 HHs were asked whether they received vaccination and an ITN during a measles campaign, as well as questions on assets (e.g. type roofing material or bicycle ownership) to assess HH wealth. Net ownership was calculated for children in each wealth quintile. In the rural areas, ITN coverage among children rose from 16.7% to 81.1% and the equity ratio from 0.32 to 0.88 and in the urban area from 50.7% to 76.2% (equity ratio: 0.66-1.19). The operational cost per ITN delivered was dollar 0.35 in the rural area with direct distribution and $1.89 in the urban areas with voucher distribution. Mass distribution of ITNs through vaccination campaigns achieves rapid, high and equitable coverage at low cost.

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.