Uncovering the Drivers of Childhood Immunization Inequality with Caregivers, Community Members and Health System Stakeholders: Results from a Human-Centered Design Study in DRC, Mozambique and Nigeria.

BACKGROUND: The importance of immunization for child survival underscores the need to eliminate immunization inequalities. Few existing studies of inequalities use approaches that view the challenges and potential solutions from the perspective of caregivers. This study aimed to identify barriers and context-appropriate solutions by engaging deeply with caregivers, community members, health workers, and other health system actors through participatory action research, intersectionality, and human-centered design lenses. METHODS: This study was conducted in the Demographic Republic of Congo, Mozambique and Nigeria. Rapid qualitative research was followed by co-creation workshops with study participants to identify solutions. We analyzed the data using the UNICEF Journey to Health and Immunization Framework. RESULTS: Caregivers of zero-dose and under-immunized children faced multiple intersecting and interacting barriers related to gender, poverty, geographic access, and service experience. Immunization programs were not aligned with needs of the most vulnerable due to the sub-optimal implementation of pro-equity strategies, such as outreach vaccination. Caregivers and communities identified feasible solutions through co-creation workshops and this approach should be used whenever possible to inform local planning. CONCLUSIONS: Policymakers and managers can integrate HCD and intersectionality mindsets into existing planning and assessment processes, and focus on overcoming root causes of sub-optimal implementation.

Prognostic Factors Associated With Progression for Advanced-Stage/G1 and G2 Small-Bowel Neuroendocrine Tumors After Multimodal Therapy: Experience From a Tertiary Referral Center.

OBJECTIVES: Neuroendocrine tumors represent approximately 40% of primary small bowel malignancies. However, factors predictive of progression after multimodal surgical therapy have not been well described. We evaluated the characteristics of small bowel neuroendocrine tumor patients associated with progression after multimodal surgical resection. METHODS: A retrospective chart review identified 99 stage III and stage IV small bowel neuroendocrine tumor patients at Mount Sinai diagnosed and treated with surgery between 2005 and 2019. Progression-free survival (PFS) was defined as time from surgery until progression in surveillance radiologic imaging. Kaplan-Meier method was used to calculate PFS. Cox proportional hazard models were used to study the prognostic factors for PFS. RESULTS: Of 99 patients, 48 had tumor progression during the follow-up period. Median PFS was 5.7 years (95% confidence interval [CI], 3.73-8.66) for the entire cohort. Prognostic factors for PFS were age at diagnosis (hazard ratio [HR], 1.04; 95% CI, 1.01-1.07), perineural invasion (HR, 2.19; 95% CI, 1.13-4.23), and elevated preoperative chromogranin level (HR, 2.31; 95% CI, 1.01-5.27). CONCLUSIONS: Age at diagnosis, perineural invasion, and elevated preoperative chromogranin level may play a prognostic role in PFS.

A cost-effectiveness analysis of traditional and geographic information system-supported microplanning approaches for routine immunization program management in northern Nigeria.

Effective RI microplanning requires accurate population estimates and maps showing health facilities and locations of villages and target populations. Traditional microplanning relies on census figures to project target populations and on community estimates of distances, while GIS microplanning uses satellite imagery to estimate target populations and spatial analyses to estimate distances. This paper estimates the cost-effectiveness of geographical information systems (GIS)-based microplanning for routine immunization (RI) programming in two states in northern Nigeria. For our cost-effectiveness analysis, we captured the cost of all inputs for both approaches to capture the incremental cost of GIS over traditional microplanning and present the incremental cost-effectiveness ratios for each vaccine-preventable illness, death, and disability-adjusted life year (DALY) averted. We considered two scenarios for estimating vaccine requirements for each microplanning approach, one based on administrative vaccination coverage rates and one based on National Nutrition and Health Survey rates. With the administrative rates, GIS microplanning projected approximately 194,000 and 157,000 more required vaccinations than traditional microplanning in Bauchi and Sokoto States; with the survey rates, the additional number of vaccinations required was nearly 113,000 in Bauchi and about 47,000 in Sokoto. For each state under each scenario, we present numbers of and costs per measles and pertussis cases, deaths, and DALYs averted by the additional vaccinations, as well as annual costs. As expected, GIS-based microplanning incurs higher costs than traditional microplanning, due mainly to the additional vaccinations required for populations previously unreached. Our estimates of cost per DALY averted suggest, however, that GIS microplanning is more cost-effective than traditional microplanning in both states under both coverage scenarios and that the higher costs incurred by GIS microplanning are worth adopting.