Strategies for scaling up pre-ART advanced HIV disease screening at a secondary referral hospital-Malawi: a qualitative study.

BACKGROUND: Implementation of the World Health Organization (WHO) recommended Advanced HIV Disease screening package, remains poor in most settings with limited resources. More than 50% of newly diagnosed-HIV clients are missed on screening as a result of implementation barriers. It is important to mitigate the existing barriers and leverage enablers' inorder to maximize uptake of the advanced HIV disease screening. This study aimed to identify strategies for scaling up implementation of advanced HIV disease screening among newly HIV-diagnosed clients in pre-ART phase using a Consolidated Framework for Implementation Research-Expert Recommendation for Implementing Change (CFIR-ERIC) guiding tool. METHODS: A qualitative study was conducted at Rumphi district hospital in Malawi (August - September, 2023). Two sessions of Focus group discussions (FDGs) involving key stakeholders were facilitated to identify specific strategies following the initial study on exploration of barriers and facilitators of advanced HIV disease screening package. Participants comprised healthcare providers, purposively selected from key hospital departments. A deductive approach was used to analyze FDG transcripts where emerging themes were mapped with ERIC list of strategies. CFIR-ERIC Matching tool version 1.0, was used to generate an output of the most to least expert-endorsed Level 1 and Level 2 strategies. FINDINGS: About 25 key healthcare workers participated in FDGs. Overall, 6 Level 1 strategies (≥ 50% expert endorsement score) and 4 Level 2 strategies (≥ 20%, ≤ 49% expert endorsement score) were identified, targeting barriers associated with availability of resources, intervention complexity, access to knowledge and information, communication; and implementation leads. Most of the reported strategies were cross-cutting and aimed at enhancing clinical knowledge of the intervention (distributing training materials, educational meetings), developing stakeholders' interrelations (network weaving) as well as improving clinical workflow (environmental restructuring). Use of evaluative and iterative strategies such as monthly data collection for evaluation were also recommended as part of continuous improvement while an AHD coordinator was recommended to be formally appointed inorder to spearhead coordination of AHD screening services. CONCLUSION: Through the involvement of key stakeholders and the use of CFIR-ERIC matching tool, this study has identified cross-cutting strategies that if well implemented, can help to mitigate contextual barriers and leverage enablers for an improved delivery of AHD screening package.

Barriers and facilitators to implementing advanced HIV disease screening at a secondary referral hospital -Malawi: a convergent parallel study.

BACKGROUND: Malawi continues to register HIV/AIDS mortality despite increased expansion of ART services and as well as advanced HIV screening as outlined in the 2020 -2025 Malawi National HIV Strategic Plan (NSP). This study aimed to explore factors influencing the implementation of the advanced HIV disease (AHD) screening package at Rumphi District Hospital, Malawi. METHODS: We conducted a mixed method, convergent study at a secondary referral hospital with 8 659 clients on ART. Guided by a consolidated framework for implementation research (CFIR) we conducted semi-structured Interviews with healthcare professionals, purposively selected from various key departments that were actively involved in AHD screening. Transcripts were organized and coded using NVivo 12 software with thematically predefined CFIR constructs. Newly HIV-positive client records extracted from ART cards (July -Dec, 2021) were analyzed using STATA 14 software. RESULTS: One hundred one ART records met inclusion criteria for review and analysis of which 60% (n = 61) of the newly diagnosed HIV clients had no documented results for CD4 Cell count. Barriers to AHD screening emerged from four major CFIR constructs: intervention complexity, communication, availability of resources and access to knowledge and information. The specific barriers included poor work coordination among implementers, limited resources to support the expansion of AHD screening, and knowledge gap among providers. External support from Ministry of Health implementing partners and the availability of committed focal leaders coordinating HIV programs emerged as major enablers of AHD screening package. CONCLUSION: The study has identified major contextual barriers to AHD screening including knowledge gap, poor communication systems and inadequate supporting resources. Improving uptake of AHD screening services would therefore require overcoming the existing barriers by adopting a comprehensive approach in developing barrier-tailored strategies.

The incidence and mortality of yellow fever in Africa: a systematic review and meta-analysis.

BACKGROUND: Understanding the occurrence of yellow fever epidemics is critical for targeted interventions and control efforts to reduce the burden of disease. We assessed data on the yellow fever incidence and mortality rates in Africa. METHODS: We searched the Cochrane Library, SCOPUS, MEDLINE, CINAHL, PubMed, Embase, Africa-wide and Web of science databases from 1 January 1975 to 30th October 2020. Two authors extracted data from included studies independently and conducted a meta-analysis. RESULTS: Of 840 studies identified, 12 studies were deemed eligible for inclusion. The incidence of yellow fever per 100,000 population ranged from < 1 case in Nigeria, < 3 cases in Uganda, 13 cases in Democratic Republic of the Congo, 27 cases in Kenya, 40 cases in Ethiopia, 46 cases in Gambia, 1267 cases in Senegal, and 10,350 cases in Ghana. Case fatality rate associated with yellow fever outbreaks ranged from 10% in Ghana to 86% in Nigeria. The mortality rate ranged from 0.1/100,000 in Nigeria to 2200/100,000 in Ghana. CONCLUSION: The yellow fever incidence rate is quite constant; in contrast, the fatality rates vary widely across African countries over the study period. Standardized demographic health surveys and surveillance as well as accurate diagnostic measures are essential for early recognition, treatment and control.

Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis.

BACKGROUND: Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination. OBJECTIVES: - Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness. SEARCH METHODS: We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020. SELECTION CRITERIA: We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided. DATA COLLECTION AND ANALYSIS: We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review. MAIN RESULTS: We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness. AUTHORS' CONCLUSIONS: Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.

Pandemic influenza preparedness in the WHO African region: are we ready yet?

BACKGROUND: Prior to the 2009 pandemic H1N1, and the unprecedented outbreak of Highly Pathogenic Avian Influenza (HPAI) caused by the H5N1 virus, the World Health Organization (WHO) called upon its Member States to develop preparedness plans in response to a new pandemic in humans. The WHO Member States responded to this call by developing national pandemic plans in accordance with the International Health Regulations (IHR) to strengthen the capabilities of Member States to respond to different pandemic scenarios. In this study, we aim to evaluate the quality of the preparedness plans in the WHO African region since their inception in 2005. METHODS: A standard checklist with 61 binary indicators ("yes" or "no") was used to assess the quality of the preparedness plans. The checklist was categorised across seven thematic areas of preparedness: preparation (16 indicators); coordination and partnership (5 indicators); risk communication (8 indicators); surveillance and monitoring (7 indicators); prevention and containment (10 indicators); case investigation and treatment (10 indicators) and ethical consideration (5 indicators). Four assessors independently scored the plans against the checklist. RESULTS: Of the 47 countries in the WHO African region, a total of 35 national pandemic plans were evaluated. The composite score for the completeness of the pandemic plans across the 35 countries was 36%. Country-specific scores on each of the thematic indicators for pandemic plan completeness varied, ranging from 5% in Côte d'Ivoire to 79% in South Africa. On average, preparation and risk communication scored 48%, respectively, while coordination and partnership scored the highest with an aggregate score of 49%. Surveillance and monitoring scored 34%, while prevention and containment scored 35%. Case investigation and treatment scored 25%, and ethical consideration scored the lowest of 14% across 35 countries. Overall, our assessment shows that pandemic preparedness plans across the WHO African region are inadequate. CONCLUSIONS: Moving forward, these plans must address the gaps identified in this study and demonstrate clarity in their goals that are achievable through drills, simulations and tabletop exercises.

Policy perspectives on post pandemic influenza vaccination in Ghana and Malawi.

BACKGROUND: In the late 1990s, in the context of renewed concerns of an influenza pandemic, countries such as Ghana and Malawi established plans for the deployment of vaccines and vaccination strategies. A new pandemic was declared in mid-June 2009, and by April 2011, Ghana and Malawi vaccinated 10% of the population. We examine the public health policy perspectives on vaccination as a means to prevent the spread of infection under post pandemic conditions. METHODS: In-depth interviews were conducted with 46 policymakers (Ghana, n = 24; Malawi, n = 22), identified through snowballing sampling. Interviews were supplemented by field notes and the analysis of policy documents. RESULTS: The use of vaccination to interrupt the pandemic influenza was affected by delays in the procurement, delivery and administration of vaccines, suboptimal vaccination coverage, refusals to be vaccinated, and the politics behind vaccination strategies. More generally, rolling-out of vaccination after the transmission of the influenza virus had abated was influenced by policymakers' own financial incentives, and government and foreign policy conditionality on vaccination. This led to confusion about targeting and coverage, with many policymakers justifying that the vaccination of 10% of the population would establish herd immunity and so reduce future risk. Ghana succeeded in vaccinating 2.3 million of the select groups (100% coverage), while Malawi, despite recourse to force, succeeded only in vaccinating 1.15 million (74% coverage of select groups). For most policymakers, vaccination coverage was perceived as successful, despite that vaccination delays and coverage would not have prevented infection when influenza was at its peak. CONCLUSIONS: While the vaccination strategy was problematic and implemented too late to reduce the effects of the 2009 epidemic, policy makers supported the overall goal of pandemic influenza vaccination to interrupt infection. In this context, there was strong support for governments engaging in contracts with pharmaceutical companies to ensure the timely supply of vaccines, and developing well-defined guidelines to address vaccination delays, refusals and coverage.

Barriers and facilitators to implementing Advanced HIV Disease screening at secondary referral hospital -Malawi: Asequential exploratory mixed method-study.

Background Malawi continues to register increased HIV/AIDs mortality despite increased expansion of ART services. One of the strategies for reducing AIDS related deaths outlined in the Malawi National HIV Strategic Plan (NSP) is scaling up screening for AHD in all antiretroviral therapy (ART) screening sites. This study investigated factors influencing the implementation of the advanced HIV disease (AHD) screening package at Rumphi District Hospital, Malawi. Methods We conducted a mixed method, sequential exploratory study from March, 2022 to July, 2022. The study was guided by a consolidated framework of implementation research (CFIR). Interviews were administered to key healthcare providers, purposively selected from various hospital departments. Transcripts were organized and coded using NVivo 12 software with thematically predefined CFIR constructs. Newly HIV-positive client records extracted from ART cards (July -Dec, 2021) were analyzed using STATA 14 which generated table of proportions, means and standard deviations. Results Out of 101 data records of the new ART clients reviewed, 60% {(n = 61) had no documented results for CD4 Cell count as a baseline screening test for AHD. Four major themes emerged as barriers: complexity of the intervention, poor work coordination, limited resources to support the expansion of point of care services for AHD, knowledge and information gap among providers. Technical support from MoH implementing partners and the availability of committed focal leaders coordinating HIV programs emerged as major facilitators of AHD screening package. Conclusion The study has identified major contextual barriers to AHD screening affecting work coordination and client linkage to care. Improving coverage of AHD screening services would therefore require overcoming the existing barriers such communication and information gaps.

Role of primary health care in ensuring access to medicines.

To examine ways of ensuring access to health services within the framework of primary health care (PHC), since the goal of PHC to make universal health care available to all people has become increasingly neglected amid emerging themes of globalization, trade, and foreign policy. From a public health point of view, we argue that the premise of PHC can unlock barriers to health care services and contribute greatly to determining collective health through the promotion of universal basic health services. PHC has the most sophisticated and organized infrastructure, theories, and political principles, with which it can deal adequately with the issues of inequity, inequality, and social injustice which emerge from negative economic externalities and neo-liberal economic policies. Addressing these issues, especially the complex social and political influences that restrict access to medicines, may require the integration of different health initiatives into PHC. Based on current systems, PHC remains the only conventional health delivery service that can deal with resilient public health problems adequately. However, to strengthen its ability to do so, we propose the revitalization of PHC to incorporate scholarship that promotes human rights, partnerships, research and development, advocacy, and national drug policies. The concept of PHC can improve access; however, this will require the urgent interplay among theoretical, practical, political, and sociological influences arising from the economic, social, and political determinants of ill health in an era of globalization.

New vaccine introductions in Africa before and during the decade of vaccines - Are we making progress?

Vaccines are excellent investments with far-reaching rewards beyond individual and population health, but their introduction into national programs has been historically slow in Africa. We provide an overview of the introduction of new and underutilized vaccines in countries of the WHO African Region by 2017, using data from the WHO-UNICEF Joint Reporting Form. By 2017, all 47 countries had introduced vaccines containing hepatitis B (compared to 11% in 2000 and 98% in 2010) and Haemophilus influenzae type b (Hib) (compared to 4% in 2000 and 91% in 2010). The proportion of countries that had introduced other vaccines by 2017 was 83% for pneumococcal conjugate vaccine (PCV) from 7% in 2010, 72% for rotavirus vaccine from 2% in 2010, 55% for the second dose of a measles-containing vaccine (MCV2) (compared to 11% in 2000 and 17% in 2010), and 45% for rubella-containing vaccines (RCV) (compared to 4% in 2000 and 7% in 2010). From 2000 to 2010, there was no significant difference between countries eligible (N = 36) and those not eligible (N = 10) for Gavi support in the introduction of hepatitis B and PCV. However, Gavi eligible countries were more likely to introduce Hib and non-Gavi eligible countries were more likely to introduce MCV2 and RCV. From 2010 to 2017, the only significant differences that remained between the two groups of countries were with mumps, inactivated polio and seasonal influenza vaccines; which non-Gavi eligible countries were more likely to have introduced. There has been significant progress in the introduction of new childhood vaccines in Africa, mostly driven by Gavi support. As many countries are expected to transition out of Gavi support soon, there is need for countries in the region to identify predictable, reliable and sustainable immunization funding mechanisms. This requires commitments and actions that go beyond the purchase of vaccines.

A global review of seasonal influenza vaccine introduction: analysis of the WHO/UNICEF Joint Reporting Form.

Background: Influenza is a highly contagious disease that affects the upper and lower respiratory tract caused by several subtypes of influenza viruses. While vaccination remains the mainstay strategy to protect populations against influenza, there is a global shortage and inequitable access to influenza vaccines. Although influenza vaccine production capacity increased from 500 million doses in 2006 to 1.5 billion doses in 2013, little is known about the global distribution of these vaccines albeit its introduction. We assessed the global status of influenza vaccine introduction. Research design and methods: We analyzed data from the World Health Organization (WHO) Joint Reporting Form, a publicly available source of immunization data from 194 countries of all six WHO regions. We used 2017 data, available as of July 2018. Results: By December 2017, 117 of 194 (60%) WHO Member States had introduced the seasonal influenza vaccine. European and American regions accounted for 70% (82/117) of the total number of countries that had introduced influenza vaccine. The other four regions account for only 30%. Ninety-four percent (50/53) of countries in the European region and 91% (32/35) in the American region had introduced influenza vaccine. In the Eastern Mediterranean and Western Pacific regions, 67% (14/21) and 52% (14/27), respectively, had introduced the vaccine. Yet only 27% (3/11) and 9% (4/47) in the Southeast Asian and African regions, respectively, had introduced the vaccine. Among countries (n = 117) that had introduced the vaccine, children (56%), older adults (87%), and risk groups (99%) were prioritized and given the vaccines. Conclusions: Introduction of influenza vaccine in the African and Southeast Asian regions remains suboptimal. This critically underscores the need for financing mechanisms and having countries in the regions that are lagging behind to prioritize seasonal influenza vaccine.

Rural-urban disparities in missed opportunities for vaccination in sub-Saharan Africa: a multi-country decomposition analyses.

BACKGROUND: In this study, we aimed to explore the rural-urban disparities in the magnitude and determinants of missed opportunities for vaccination (MOV) in sub-Saharan Africa. METHODS: This was a cross-sectional study using nationally representative household surveys conducted between 2007 and 2017 in 35 countries across sub-Saharan Africa. The risk difference in MOV between rural or urban dwellers were calculated. Logistic regression method was used to investigate the urban-rural disparities in multivariable analyses. Then Blinder-Oaxaca method was used to decompose differences in MOV between rural and urban dwellers. RESULTS: The median number of children aged 12 to 23 months was 2113 (Min: 370, Max: 5896). There was wide variation in the the magnitude of MOV among children in rural and urban areas across the 35 countries. The magnitude of MOV in rural areas varied from 18.0% (95% CI 14.7 to 21.4) in the Gambia to 85.2% (81.2 to 88.9) in Gabon. Out of the 35 countries included in this analysis, pro-rural inequality was observed in 16 countries (i.e. MOV is prevalent among children living in rural areas) and pro-urban inequality in five countries (i.e. MOV is prevalent among children living in urban areas). The contributions of the compositional 'explained' and structural 'unexplained' components varied across the countries. However, household wealth index was the most frequently identified factor. CONCLUSIONS: Variation exists in the level of missed opportunities for vaccination between rural and urban areas, with widespread pro-rural inequalities across Africa. Although several factors account for these rural-urban disparities in various countries, household wealth was the most common.

Vaccine hesitancy - a potential threat to the achievements of vaccination programmes in Africa.

Vaccination programmes in Africa have made extraordinary progress over the last four decades. Yet, vaccine hesitancy threatens to erode these gains. Vaccine hesitancy is a continuum between vaccine acceptance and refusal. A growing number of people in Africa are delaying or refusing recommended vaccines for themselves or their children, even when safe and effective vaccines are available. This predisposes communities to infectious diseases, resulting in multiple disease outbreaks, ultimately consuming resources and costing lives. Vaccine hesitancy is currently receiving unprecedented global attention, however, there remains several knowledge gaps, particularly in Africa. The vast majority of research on this topic has been conducted in high income countries. Little is therefore known about the nature and causes of vaccine hesitancy in Africa, and evidence-based interventions in the region to address it are also limited. Moreover, tools to measure vaccine hesitancy are scarce, and none that exist have been validated in Africa. We discuss these knowledge gaps, and propose a research and capacity building agenda to better measure and overcome vaccine hesitancy in Africa. Ultimately, this is essential if we hope to enhance and sustain public demand for vaccination and preserve the tremendous achievements of vaccination programmes on the continent.

Existence and functionality of national immunisation technical advisory groups in Africa from 2010 to 2016.

We describe the existence and functionality of National Immunisation Technical Advisory Groups (NITAGs) in Africa between 2010 and 2016, using data from the WHO-UNICEF Joint Reporting Form. The number of African countries with NITAGs increased from 15 (28%) in 2010 to 26 (48%) in 2016. Countries with a functioning NITAG increased from 5(9%) in 2010 to 16 (30%) in 2016. In 2016, 13 of the 27 (48%) low-income African countries reported having a NITAG; seven (54%) of them functional. Thirteen of the 26 (50%) middle-income countries reported having a NITAG; nine (69%) of them functional. In 2016, six of the seven African countries (86%) in the WHO Eastern Mediterranean Region had a NITAG, with three (50%) functional. In the WHO African Region, 20 of the 47 countries (43%) had NITAGs; 13 (65%) of them functional. Substantial investments should be made to ensure that every African country has a functional NITAG.

Mind the Gap: What explains the education-related inequality in missed opportunities for vaccination in sub-Saharan Africa? Compositional and structural characteristics.

Missed opportunities for vaccination (MOV) is an important barrier hindering full immunisation coverage among eligible children. Though factors responsible for MOV are well documented in literature, little attention has been paid to the role of inequalities. The aim of this study is to examine the association between structural or compositional factors and education inequalities in MOV. Blinder-Oaxaca decomposition technique was used to explain the factors contributing to the average gap in missed opportunities for vaccination between uneducated and educated mothers in sub-Saharan Africa using DHS survey data from 35 sub Saharan African countries collected between 2007 and 2016. The sample contained 69,657 children aged 12 to 23 months. We observed a wide variation and inter-country differences in the prevalence of missed opportunity for vaccination across populations and geographical locations. Our results show that the prevalence of MOV in Zimbabwe among uneducated and educated mothers was 9% and 21% respectively while in Gabon corresponding numbers were 85% and 89% respectively. In 15 countries, MOV was significantly prevalent among children born to uneducated mothers (pro-illiterate inequality) while in 5 countries MOV was significantly prevalent among educated mothers (pro-educated inequality). Our results suggest that education-related inequalities in missed opportunities for vaccination are explained by compositional and structural characteristics; and that neighbourhood socio-economic status was the most important contributor to education-related inequalities across countries followed by either the presence of under-five children, media access or household wealth index. The results showed that differential effects such as neighbourhood socio-economic status, presence of under-five children, media access and household wealth index, primarily explained education-related inequality in MOV. Interventions to reduce gaps in education-related inequality in MOV should focus on social determinants of health.

Decomposing the gap in missed opportunities for vaccination between poor and non-poor in sub-Saharan Africa: A Multicountry Analyses.

Understanding the gaps in missed opportunities for vaccination (MOV) in sub-Saharan Africa would inform interventions for improving immunisation coverage to achieving universal childhood immunisation. We aimed to conduct a multicountry analyses to decompose the gap in MOV between poor and non-poor in SSA. We used cross-sectional data from 35 Demographic and Health Surveys in SSA conducted between 2007 and 2016. Descriptive statistics used to understand the gap in MOV between the urban poor and non-poor, and across the selected covariates. Out of the 35 countries included in this analysis, 19 countries showed pro-poor inequality, 5 showed pro-non-poor inequality and remaining 11 countries showed no statistically significant inequality. Among the countries with statistically significant pro-illiterate inequality, the risk difference ranged from 4.2% in DR Congo to 20.1% in Kenya. Important factors responsible for the inequality varied across countries. In Madagascar, the largest contributors to inequality in MOV were media access, number of under-five children, and maternal education. However, in Liberia media access narrowed inequality in MOV between poor and non-poor households. The findings indicate that in most SSA countries, children belonging to poor households are most likely to have MOV and that socio-economic inequality in is determined not only by health system functions, but also by factors beyond the scope of health authorities and care delivery system. The findings suggest the need for addressing social determinants of health.

Does it really matter where you live? A multilevel analysis of factors associated with missed opportunities for vaccination in sub-Saharan Africa.

There is an urgent need to examine the magnitude and factors responsible for missed opportunities for vaccination, to rapidly achieve national immunization targets. The objective of the study was to examine the influence of individual, neighbourhood and country level socioeconomic position on missed opportunities for vaccination (MOV) in Sub-Saharan Africa. We used multilevel logistic regression analysis on Demographic and Health Survey data collected between 2007 and 2016 in sub-Saharan Africa. We analysed data on 43,637 children aged 12 to 23 months (Level 1) nested within 15,122 neighbourhoods (Level 2) from 35 countries (Level 3). After adjustment for individual-, neighbourhood- and country-level factors, the following appeared as significant risk factors for increased odds of MOV: high birth order, high number of under-five children in the house, poorest household, lack of maternal education, lack of media access, and living in poorer neighbourhood. According to the intra-country and intra-neighbourhood correlation coefficient, 18.4% and 37.4% of the variance in odds of MOV could be attributed to the country and neighbourhood level factors, respectively; and if a child moved to another country or neighbourhood with a higher probability of MOV, the median increase in their odds of MOV would be 2.47 and 2.56 fold respectively. This study has revealed that the risk of missed opportunities for vaccination in sub-Saharan Africa is influenced by not only individual factors but also by compositional factors such as family's financial capacity, place of birth and upbringing.

Anticipation and response: pandemic influenza in Malawi, 2009.

BACKGROUND: In 2006, Malawi developed a national influenza plan to mitigate, prevent and manage the burden of infection should an outbreak occur. In 2009, it translated its contingency plan to respond to the unfolding influenza pandemic. However, little is known of how Malawi translated its national influenza plan into response actions, or the success of these responses. OBJECTIVE: To investigate how Malawi translated its preparedness plan and so broaden our understanding of the outcomes of the responses. METHODS: We draw on data from 22 in-depth interviews with government policymakers and people working at a policy level in various non-governmental organisations, conducted to assess the level of preparedness and the challenges of translating this. RESULTS: Through a number of public health initiatives, authorities developed communication strategies, strengthened influenza surveillance activities and updated overall goals in pandemic training and education. However, without influenza drills, exercises and simulations to test the plan, activating the pandemic plan, including coordinating and deploying generic infection control measures, was problematic. Responses during the pandemic were at times 'weak and clumsy' and failed to mirror the activities and processes highlighted in the preparedness plan. CONCLUSIONS: Participants stressed that in order to achieve a coordinated and successful response to mitigate and prevent the further transmission of pandemic influenza, good preparation was critical. The key elements which they identified as relevant for a rapid response included effective communications, robust evidence-based decision-making, strong and reliable surveillance systems and flexible public health responses. To effectively articulate a viable trajectory of pandemic responses, the potential value of simulation exercises could be given more consideration as a mean of sustaining good levels of preparedness and responses against future pandemics. These all demand a well-structured planning for and response to pandemic influenza strategy developed by a functioning scientific and policy advisory committee.