Integrating maternal, newborn, child health and non-communicable disease care in the sustainable development goal era.

Noncommunicable diseases (NCDs) and maternal newborn and child health (MNCH) are two deeply intertwined health areas that have been artificially separated by global health policies, resource allocations and programming. Optimal MNCH care can provide a unique opportunity to screen for, prevent and manage early signs of NCDs developing in both the woman and the neonate. This paper considers how NCDs, NCD modifiable risk factors, and NCD metabolic risk factors impact MNCH. We argue that integrated management is essential, but this faces challenges that manifest across all levels of domestic health systems. Progress toward Sustainable Development targets requires joined-up action.

Contribution of Global Polio Eradication Initiative-Funded Personnel to the Strengthening of Routine Immunization Programs in the 10 Focus Countries of the Polio Eradication and Endgame Strategic Plan.

Background: The Polio Eradication and Endgame Strategic Plan (PEESP) established a target that at least 50% of the time of personnel receiving funding from the Global Polio Eradication Initiative (GPEI) for polio eradication activities (hereafter, "GPEI-funded personnel") should be dedicated to the strengthening of immunization systems. This article describes the self-reported profile of how GPEI-funded personnel allocate their time toward immunization goals and activities beyond those associated with polio, the training they have received to conduct tasks to strengthen routine immunization systems, and the type of tasks they have conducted. Methods: A survey of approximately 1000 field managers of frontline GPEI-funded personnel was conducted by Boston Consulting Group in the 10 focus countries of the PEESP during 2 phases, in 2013 and 2014, to determine time allocation among frontline staff. Country-specific reports on the training of GPEI-funded personnel were reviewed, and an analysis of the types of tasks that were reported was conducted. Results: A total of 467 managers responded to the survey. Forty-seven percent of the time (range, 23%-61%) of GPEI-funded personnel was dedicated to tasks related to strengthening immunization programs, other than polio eradication. Less time was spent on polio-associated activities in countries that had already interrupted wild poliovirus (WPV) transmission, compared with findings for WPV-endemic countries. All countries conducted periodic trainings of the GPEI-funded personnel. The types of non-polio-related tasks performed by GPEI-funded personnel varied among countries and included surveillance, microplanning, newborn registration and defaulter tracing, monitoring of routine immunization activities, and support of district immunization task teams, as well as promotion of health behaviors, such as clean-water use and good hygiene and sanitation practices. Conclusion: In all countries, GPEI-funded personnel perform critical tasks in the strengthening of routine immunization programs and the control of measles and rubella. In certain countries with very weak immunization systems, GPEI-funded personnel provide critical support for the immunization programs, and sudden discontinuation of their employment would potentially disrupt the immunization programs in their countries and create a setback in capacity and effectiveness that would put children at higher risk for vaccine-preventable diseases.

Experiences and Lessons From Polio Eradication Applied to Immunization in 10 Focus Countries of the Polio Endgame Strategic Plan.

Nine polio areas of expertise were applied to broader immunization and mother, newborn and child health goals in ten focus countries of the Polio Eradication Endgame Strategic Plan: policy & strategy development, planning, management and oversight (accountability framework), implementation & service delivery, monitoring, communications & community engagement, disease surveillance & data analysis, technical quality & capacity building, and partnerships. Although coverage improvements depend on multiple factors and increased coverage cannot be attributed to the use of polio assets alone, 6 out of the 10 focus countries improved coverage in three doses of diphtheria tetanus pertussis containing vaccine between 2013 and 2015. Government leadership, evidence-based programming, country-driven comprehensive operational annual plans, community partnership and strong accountability systems are critical for all programs and polio eradication has illustrated these can be leveraged to increase immunization coverage and equity and enhance global health security in the focus countries.

The acceptability of three vaccine injections given to infants during a single clinic visit in South Africa.

BACKGROUND: The Expanded Programme on Immunisation (EPI) has increased the number of antigens and injections administered at one visit. There are concerns that more injections at a single immunisation visit could decrease vaccination coverage. We assessed the acceptability and acceptance of three vaccine injections at a single immunisation visit by caregivers and vaccinators in South Africa. METHODS: A mixed methods exploratory study of caregivers and vaccinators at clinics in two provinces of South Africa was conducted. Quantitative and qualitative data were collected using questionnaires as well as observations of the administration of three-injection vaccination sessions. RESULTS: The sample comprised 229 caregivers and 98 vaccinators. Caregivers were satisfied with the vaccinators' care (97 %) and their infants receiving immunisation injections (93 %). However, many caregivers, (86 %) also felt that three or more injections were excessive at one visit. Caregivers had limited knowledge of actual vaccines provided, and reasons for three injections. Although vaccinators recognised the importance of informing caregivers about vaccination, they only did this sometimes. Overall, acceptance of three injections was high, with 97 % of caregivers expressing willingness to bring their infant for three injections again in future visits despite concerns about the pain and discomfort that the infant experienced. Many (55 %) vaccinators expressed concern about giving three injections in one immunisation visit. However, in 122 (95 %) observed three-injection vaccination sessions, the vaccinators administered all required vaccinations for that visit. The remaining seven vaccinations were not completed because of vaccine stock-outs. CONCLUSIONS: We found high acceptance by caregivers and vaccinators of three injections. Caregivers' poor understanding of reasons for three injections resulted from limited information sharing by vaccinators for caregivers. Acceptability of three injections may be improved through enhanced vaccinator-caregiver communication, and improved management of infants' pain. Vaccinator training should include evidence-informed ways of communicating with caregivers and reducing injection pain. Strategies to improve acceptance and acceptability of three injections should be rigorously evaluated as part of EPI's expansion in resource-limited countries.

Global routine vaccination coverage, 2014.

The year 2014 marked the 40th anniversary of the World Health Organization's (WHO) Expanded Program on Immunization, which was established to ensure equitable access to routine immunization services (1). Since 1974, global coverage with the four core vaccines (Bacille Calmette- Guérin vaccine [BCG; for protection against tuberculosis], diphtheria-tetanus-pertussis [DTP] vaccine, poliovirus vaccine, and measles vaccine) has increased from <5% to ≥85%, and additional vaccines have been added to the recommended schedule. Coverage with the 3rd dose of DTP vaccine (DTP3) by age 12 months is an indicator of immunization program performance because it reflects completion of the basic infant immunization schedule; coverage with other vaccines, including the 3rd dose of poliovirus vaccine (polio3); the 1st dose of measles-containing vaccine (MCV1) is also assessed. Estimated global DTP3 coverage has remained at 84%­86% since 2009, with estimated 2014 coverage at 86%. Estimated global coverage for the 2nd routine dose of measles-containing vaccine (MCV2) was 38% by age 24 months and 56% when older age groups were included, similar to levels reported in 2013 (36% and 55%, respectively). To reach and sustain high immunization coverage in all countries, adequate vaccine stock management and additional opportunities for immunization, such as through routine visits in the second year of life, are integral components to strengthening immunization programs and reducing morbidity and mortality from vaccine preventable diseases.

Global routine vaccination coverage, 2013.

In 1974, the World Health Organization (WHO) established the Expanded Program on Immunization to ensure that all children have access to routinely recommended vaccines. Since then, global coverage with the four core vaccines (Bacille Calmette-Guérin vaccine [for protection against tuberculosis], diphtheria-tetanus-pertussis vaccine [DTP], polio vaccine, and measles vaccine) has increased from <5% to ≥84%, and additional vaccines have been added to the recommended schedule. Coverage with the third dose of DTP vaccine (DTP3) by age 12 months is a key indicator of immunization program performance. Estimated global DTP3 coverage has remained at 83%-84% since 2009, with estimated 2013 coverage at 84%. Global coverage estimates for the second routine dose of measles-containing vaccine (MCV2) are reported for the first time in 2013; global coverage was 35% by the end of the second year of life and 53% when including older age groups. Improvements in equity of access and use of immunization services will help ensure that all children are protected from vaccine-preventable diseases.

Strengthening the partnership between routine immunization and the global polio eradication initiative to achieve eradication and assure sustainability.

Since the launch of the Global Polio Eradication Initiative (GPEI) in 1988, the number of polio endemic countries has declined from 125 to 3 in 2013. Despite this remarkable achievement, ongoing circulation of wild poliovirus in polio-endemic countries and the increase in the number of circulating vaccine-derived poliovirus cases, especially those caused by type 2, is a cause for concern. The Polio Eradication and Endgame Strategic Plan 2013-2018 (PEESP) was developed and includes 4 objectives: detection and interruption of poliovirus transmission, containment and certification, legacy planning, and a renewed emphasis on strengthening routine immunization (RI) programs. This is critical for the phased withdrawal of oral poliovirus vaccine, beginning with the type 2 component, and the introduction of a single dose of inactivated polio vaccine into RI programs. This objective has inspired renewed consideration of how the GPEI and RI programs can mutually benefit one another, how the infrastructure from the GPEI can be used to strengthen RI, and how a strengthened RI can facilitate polio eradication. The PEESP is the first GPEI strategic plan that places strong and clear emphasis on the necessity of improving RI to achieve and sustain global polio eradication.

Quantitative studies on roast kinetics for bioactives in coffee.

Quantitative analysis of the bioactives trigonelline (1), N-methylpyridinium (2), caffeine (3), and caffeoylquinic acids (4) in a large set of roasted Arabica (total sample size n = 113) and Robusta coffees (total sample size n = 38) revealed that the concentrations of 1 and 4 significantly correlated with the roasting color (P < 0.001, two tailed), whereas that of 2 significantly correlated inversely with the color (P < 0.001, two tailed). As dark-roasted coffees were rich in N-methylpyridinium whereas light-roasted coffees were rich in trigonelline and caffeoylquinic acids, manufacturing of roast coffees rich in all four bioactives would therefore necessitate blending of two or even more coffees of different roasting colors. Additional experiments on the migration rates during coffee brewing showed that all four bioactives were nearly quantitatively extracted in the brew (>90%) when a water volume/coffee powder ratio of >16 was used.

Dissolving carbon dioxide in high viscous substrates to accelerate biocatalytic reactions.

Solvent free biotransformation of polyglycerol-3 and lauric acid yields polyglycerol-3-laurate and water. This conversion can be catalyzed by Novozym 435. However, the performance is limited by the viscosity of polyglycerol as well as of polyglycerol-3-laurate. A decrease of viscosity by increasing reaction temperature is only possible in a certain temperature range because of the limited stability of the applied enzyme. By dissolving high dense carbon dioxide into the reaction system the viscosity could be reduced, keeping the temperature at an acceptable level at the same time. Thus the reaction rate was increased by a factor of 4 while working at a pressure of 280 bar and 60°C.

Development of a hydrophilic liquid interaction chromatography-high-performance liquid chromatography-tandem mass spectrometry based stable isotope dilution analysis and pharmacokinetic studies on bioactive pyridines in human plasma and urine after coffee consumption.

The paper reports on the development of an accurate hydrophilic liquid interaction chromatography tandem mass spectrometry (HILIC-MS/MS) based stable isotope dilution analysis for the simultaneous quantitation of the food-derived bioactive pyridines trigonelline, nicotinic acid, nicotinamide, and N-methylpyridinium, as well as their key metabolites nicotinamide-N-oxide, N-methylnicotinamide, N-methyl-2-pyridone-5-carboxamide, N-methyl-4-pyridone-5-carboxamide, and N-methyl-2-pyridone-5-carboxylic acid in human plasma and urine. Precision of the stable isotope dilution analysis (SIDA) was 1.9% and 11.9% relative standard deviation (n = 6), and accuracy was between 92.4% and 113.0%. The lower limit of quantitation (LLOQ) was 50 fmol (10 pmol/mL) injected onto the column for all analytes with the exception of N-methyl-2-pyridone-5-carboxylic acid and N-methyl-2-pyridone-5-carboxamide, for which an LLOQ of 100 fmol (20 pmol/mL) was found. The method was applied to monitor the plasma appearance and urinary excretion and to determine pharmacokinetic parameters of the bioactive pyridines as well as their metabolites in a clinical human intervention study with healthy volunteers (six women, seven men) after oral administration of 350 mL of a standard coffee beverage. Trigonelline plasma levels increased from 160 nmol/L to maximum concentrations of 5479 (males) or 6547 nmol/L (females), and N-methylpyridinium plasma levels raised from virtually complete absence to maximum values of 777 (females) or 804 nmol/L (males) within 2-3 and 1-2 h after coffee consumption, respectively. The high plasma levels of N-methylpyridinium found after coffee consumption clearly demonstrate for the first time that this cation is entering the vascular system, which is the prerequisite for biological in vivo effects claimed for that compound. In contrast, the coffee intervention did not significantly influence the plasma concentrations of N-methyl-2-pyridone-5-carboxamide and N-methyl-4-pyridone-5-carboxamide, the major niacin metabolites. Within 8 h after coffee intervention, an urinary excretion of 57.4 +/- 6.9% of trigonelline and 69.1 +/- 6.2% of N-methylpyridinium was found for the male volunteers, whereas females excreted slightly less with 46.2 +/- 7.4% and 61.9 +/- 12.2% of these pyridines.

Quantitative investigation of trigonelline, nicotinic acid, and nicotinamide in foods, urine, and plasma by means of LC-MS/MS and stable isotope dilution analysis.

A straightforward stable isotope dilution analysis (SIDA) for the quantitative determination of trigonelline, nicotinic acid, and nicotinamide in foods such as coffee, as well as in biological samples by means of LC-MS/MS (MRM) has been developed. The coefficients of variation for their quantitative analysis in a coffee sample were 2.1% for trigonelline, 1.1% for nicotinic acid, and 3.1% for nicotinamide, and recovery experiments showed good results between 98.5 and 104.5%. Application of this SIDA for the quantification of trigonelline, nicotinic acid, and nicotinamide in coffee samples of different roasting degrees revealed a drastic degradation of trigonelline as well as the generation of nicotinic acid accounting for 4-6% of the initial trigonelline content, whereas nicotinamide remained rather constant at a low level. Besides the analysis of coffee samples, the feasibility of the developed SIDA was verified by analysis of other foods including breakfast cereals, rice, liver, and herring, as well as human urine and plasma samples.