Assessment of vaccine wastage rates, missed opportunities, and related knowledge, attitudes and practices during introduction of a second dose of measles-containing vaccine into Cambodia's national immunization program.

INTRODUCTION: Missed opportunities for vaccination (MOV) can result in inadequate protection against disease. Although healthcare provider reluctance to open multi-dose, lyophilized vaccine vials (particularly the measles-containing vaccine [MCV]) for every eligible child due to concerns about wasting vaccine is a known reason for MOV, little is known about providers' related attitudes and practices. METHODS: In 100 randomly selected health facilities and 24 districts of Cambodia, we surveyed healthcare providers and their district supervisors regarding routine vaccine administration and wastage knowledge and practices, and child caregivers (five per facility) regarding MOV. Vaccine stock management data covering six months were reviewed to calculate facility and district level wastage rates and vaccine usage patterns for six vaccines, including a recently introduced second dose of MCV (MCV2). RESULTS: Response rates were 100/100 (100%) among facility staff, 48/48 (100%) among district staff, and 436/500 (87%) among caregivers. Mean facility-level wastage rates varied from 4% for single-dose diphtheria-tetanus-pertussis-hepatitis B-Haemophilus influenzae type b vaccine to 60% for 10-dose MCV; district-level wastage rates for all vaccines were 0%. Some vaccines had lower wastage rates in large facilities compared to small facilities. The mean MCV wastage rate was the same before and immediately after MCV2 introduction. Providers reported waiting for a mean of two children prior to opening an MCV vial, and 71% of providers reported offering MCV vaccination less frequently during scheduled vaccination sessions than other vaccines. Less than 5% of caregivers reported that their child had been turned away for vaccination, most frequently (65%) for MCV. DISCUSSION: Although the MCV wastage rate in our study was in line with national targets, providers reported waiting for more than one child before opening an MCV vial, contrary to vaccine management guidelines. Future research should explore the causal links between provider practices related to vaccine wastage and their impact on vaccination coverage.

Impact of integration of hygiene kit distribution with routine immunizations on infant vaccine coverage and water treatment and handwashing practices of Kenyan mothers.

Integration of immunizations with hygiene interventions may improve use of both interventions. We interviewed 1361 intervention and 1139 comparison caregivers about hygiene practices and vaccination history, distributed water treatment and hygiene kits to caregivers during infant vaccination sessions in intervention clinics for 12 months, and conducted a followup survey of 2361 intervention and 1033 comparison caregivers. We observed significant increases in reported household water treatment (30% vs 44%, P < .0001) and correct handwashing technique (25% vs 51%, P < .0001) in intervention households and no changes in comparison households. Immunization coverage improved in both intervention and comparison infants (57% vs 66%, P = .04; 37% vs 53%, P < .0001, respectively). Hygiene kit distribution during routine immunizations positively impacted household water treatment and hygiene without a negative impact on vaccination coverage. Further study is needed to assess hygiene incentives, implement alternative water quality indicators, and evaluate the impact of this intervention in other settings.

Integration of routine vaccination and hygiene interventions: a comparison of 2 strategies in Kenya.

BACKGROUND: Hygiene interventions reduce child mortality from diarrhea. Vaccination visits provide a platform for delivery of other health services but may overburden nurses. We compared 2 strategies to integrate hygiene interventions with vaccinations in Kenya's Homa Bay district, 1 using community workers to support nurses and 1 using nurses. METHODS: Homa Bay was divided into 2 geographical areas, each with 9 clinics. Each area was randomly assigned to either the nurse or community-assisted strategy. At infant vaccination visits hygiene kits were distributed by the nurse or community member. Surveys pre- and post-intervention, measured hygiene indicators and vaccination coverage. Interviews and focus groups assessed acceptability. RESULTS: Between April 2009 and March 2010, 39 158 hygiene kits were distributed. Both nurse and community-assisted strategies were well-accepted. Hygiene indicators improved similarly in nurse and community sites. However, residual chlorine in water changed in neither group. Vaccination coverage increased in urban areas. In rural areas coverage either remained unchanged or increased with 1 exception (13% third dose poliovirus vaccine decrease). CONCLUSIONS: Distribution of hygiene products and education during vaccination visits was found to be feasible using both delivery strategies. Additional studies should consider assessing the use of community members to support integrated service delivery.

Do racial and ethnic differences in serum folate values exist after food fortification with folic acid?

OBJECTIVE: The United States food supply has been fortified with folic acid since 1998. Information about folate levels early in pregnancy before the fortification is limited. This study examined the associations between serum folate at first prenatal visit and maternal race/ethnicity, age, vitamin use, and body mass index. STUDY DESIGN: This cross-sectional study assessed serum folate levels among 9421 women who entered prenatal care in 1999 and 2000 in southern California. Information on race/ethnicity, vitamin use, weight, height, and age was obtained from surveys and birth certificates. RESULTS: After adjustment for vitamin use, the strongest predictor of serum folate level, being in the lowest folate quartile (< or = 16 ng/mL) was related independently to being of black, Hispanic, or Asian/Pacific Islander race/ethnicity, being younger age, and being overweight or obese. CONCLUSION: After food fortification with folic acid, differences in serum folate values in pregnant women by maternal race/ethnicity, age, and body mass index persisted.

Intent to become pregnant as a predictor of exposures during pregnancy: is there a relation?

OBJECTIVE: To evaluate the relationship between intent to be pregnant and selected maternal exposures during pregnancy. STUDY DESIGN: In 1982-1983, 3,029 women who gave birth to infants without birth defects from 1968-1980 (the control mothers from a large case-control study of birth defects) completed a detailed telephone interview. This analysis examined behaviors reported in the third month of pregnancy because most women would be aware of their pregnancies by the end of the first trimester, and our primary interest was assessing exposures that occurred after pregnancy recognition. RESULTS: Women who reported unintended pregnancies tended to be younger, nonwhite and less educated, and tended to have higher gravidity than women who reported intended pregnancies. After adjustingfor maternal age, education, race and previous adverse pregnancy outcome, women who reported unintended pregnancies were more likely to report smoking (odds ratio [OR] = 1.4, 95% confidence interval [CI] 1.2, 1.7), illicit drug use (OR=3.4, 95% CI 1.9, 6.4), not taking vitamins (OR = 1.4, 95% CI 1.2, 1.7), and alcohol use (OR=1.2, 95% CI 0.99, 1.4) than women who had intended pregnancies. No association was observed between pregnancy intention and medication use. CONCLUSION: These results suggest that women who report having unintended pregnancies are more likely to have some exposures that may result in adverse pregnancy outcomes.

Maternal obesity, gestational diabetes, and central nervous system birth defects.

BACKGROUND: Maternal obesity and diabetes are both associated with increased risk of congenital central nervous system (CNS) malformations in the offspring and may share a common underlying mechanism. Our objective was to evaluate whether gestational diabetes influenced the association of prepregnancy maternal obesity and risks for CNS birth defects. METHODS: This Texas population-based case-control study evaluated births occurring January 1997 through June 2001. Data came from structured telephone interviews. Cases (n=477) were mothers of offspring with anencephaly (n=120), spina bifida (n=184), holoprosencephaly (n=49), or isolated hydrocephaly (n=124). Controls (n=497) were mothers of live infants without abnormalities randomly selected from the same hospitals as cases. Response rates were approximately 60% for both cases and controls. We evaluated maternal obesity (body mass index > or =30.0 kg/m) and risks for CNS birth defects, as well as whether gestational diabetes influenced the risks. RESULTS: After adjusting for maternal ethnicity, age, education, smoking, alcohol use, and periconceptional vitamin use, obese women had substantially increased risks of delivering offspring with anencephaly (odds ratio=2.3; 95% confidence interval=1.2-4.3), spina bifida (2.8; 1.7-4.5), or isolated hydrocephaly (2.7; 1.5-5.0), but not holoprosencephaly (1.4; 0.5-3.8). Odds ratios were higher for the joint effects of maternal obesity and gestational diabetes, with evidence for interaction on a multiplicative scale. CONCLUSIONS: Maternal obesity and gestational diabetes may increase the risk of CNS birth defects through shared causal mechanisms.

Food fortification with folic acid and rate of multiple births, 1994-2000.

BACKGROUND: Since fortification of cereal grain products with synthetic folic acid (FA) became mandatory in January 1998, women in the United States who have become pregnant have been exposed to a higher level of FA than women who became pregnant previously. Some studies have suggested that increased FA consumption might increase the risk of multiple gestation pregnancies. METHODS: Women who had a live birth in Kaiser Foundation Health Plan hospitals from January 1, 1994 through December 31, 2000; all multiple births; and the use of ovulation-inducing drugs were ascertained from electronic databases. Medical records of a sample of women with multiple births who did not use ovulation-inducing drugs were reviewed to determine whether they used assisted reproductive technology. Exposure to FA-fortified foods was based on date of delivery. RESULTS: The rate of multiple births increased from 13.6 to 14.8 per 1000 live births from 1994 through 2000. The percentage of women who had a multiple birth and who filled a prescription for an ovulation-inducing drug in the 12 months before delivery increased from a low of 6.6% in 1994 to a high of 14.9% in 2000. After excluding women using ovulation-inducing drugs, the increased rate of multiple births was no longer observed. CONCLUSIONS: While the rates of multiple births have increased since FA fortification became mandatory, this increase can be explained by the increased use of ovulation-inducing drugs. Our findings show no relationship between food fortification with FA and the rates of multiple births in this large, managed health care population.

Effectiveness of a free folic acid supplement program in family planning clinics.

BACKGROUND: Adequate periconceptional folic acid consumption lowers the risk for neural tube defects. We report the results of an evaluation of a folic acid intervention in Georgia family planning clinics that provided free folic acid supplements or fortified breakfast cereal. METHODS: Six family planning clinics participated in the evaluation. Three clinics provided folic acid pills and educational materials to clients, two provided super-fortified cereal and educational materials, and one clinic provided educational materials only. Participants between the ages of 18 and 45 who visited the clinics in 2000 completed a brief survey and provided a blood sample. Of the 1093 women who participated, we evaluated the 165 women who had returned to the clinic at least once during the study period. We compared participants' survey and serum folate data from their first and subsequent visits. RESULTS: Participation in the intervention was associated with increased knowledge about folic acid, (odds ratio, 1.94; 95% confidence interval, 1.37-2.76), but was not directly associated with increased self-reported folic acid consumption or increased serum folate levels. Reported use of folic acid supplements or cereal within two days of a visit was associated with higher serum folate levels. Knowledge about folic acid was one of the best predictors of self-reported folic acid consumption. CONCLUSIONS: Participation in the intervention increased clients' knowledge about folic acid but did not directly increase reported folic acid consumption. Because knowledge predicted folic acid consumption, the intervention may be indirectly associated with increased consumption of folic acid.

Subfertility and prepregnancy overweight/obesity: possible interaction between these risk factors in the etiology of congenital renal anomalies.

BACKGROUND: Maternal subfertility and high body mass index (BMI) are both associated with adverse reproductive outcomes, including some birth defects. One study reported an association between subfertility and renal anomalies (Li, 1999). METHODS: We defined subfertility as the mother's report that she sought fertility treatment from a doctor/clinic, and high BMI as a prepregnancy BMI > or = 25. We included 169 infants with renal anomalies (renal agenesis [n = 41], obstructive defects [n = 117], and duplication defects [n = 11]) and 2763 infants without defects who were born in 1968-1980 in metropolitan Atlanta, after excluding mothers who reported diabetes. Conditional logistic regression (matching variables: race, birth hospital, and birth period) was used to obtain effect estimates (adjusted for maternal age and gestational age). RESULTS: Subfertility was more common among case-mothers (11.8%) than control-mothers (7.8%), high BMI was similar among case-mothers (11.2%) and control-mothers (10.9%), and joint exposure (subfertility and high BMI) was reported by 3% case-mothers and 0.7% of control-mothers. Joint exposure to subfertility and high BMI was associated with renal anomalies (odds ratio [OR] = 5.8; 95% confidence interval [CI] = 2.0-16.3). All case-mothers who reported a joint exposure had infants with obstructive renal anomalies (OR = 8.5; 95% CI = 2.9-24.7). There was no association observed for either exposure alone (subfertility and low BMI, or high BMI and no subfertility) for either all renal anomalies or obstructive defects. CONCLUSIONS: Women who are overweight/obese and experience subfertility may be more likely to have an infant with an obstructive renal anomaly. Further exploration of possible biologic mechanisms is needed.

Design and evaluation of interventions promoting periconceptional multivitamin use.

BACKGROUND: Periconceptional folic acid use reduces the risk of neural tube defects and possibly other birth defects. The effectiveness of two interventions to increase the use of multivitamins among women of childbearing ages was evaluated. METHODS: Quasi-experimental interrupted time series design with a nonequivalent control group. Participants included female members of Kaiser Foundation Health Plan aged 18 to 39 years residing in the three geographic service areas of California under study from 1998 through 2000. The central component of the direct mail/pharmacy information intervention was the mailing of "starter kits" of 100 multivitamins, while the provider education intervention used primary care providers to deliver the study message. Main outcomes included the use of multivitamins containing folic acid at least four times per week ("regularly"), intention to use multivitamins regularly, and knowledge and attitudes about multivitamins. Outcomes were measured via telephone interviews of nonpregnant women of childbearing age. RESULTS: A total of 3438 women were interviewed. There was a small but significant increase in the percentage of women using multivitamins in the direct mail/pharmacy information intervention group at the beginning of the intervention period (p =0.006), but this increase was not sustained after the interventions ended. No other significant change was observed. CONCLUSIONS: Despite our ability to reach many women of childbearing age with multiple messages about regularly using multivitamins, only a small temporary increase was found in the percentage of women using multivitamins who received the messages in the mail. Other interventions and further evaluation of the impact of food fortification with folic acid should be considered.

Maternal obesity and risk for birth defects.

OBJECTIVE: Several studies have shown an increased risk for neural tube defects associated with prepregnancy maternal obesity. Because few recent studies have examined the relation between maternal prepregnancy obesity and overweight and other birth defects, we explored the relation for several birth defects and compared our findings with those of previous studies. METHODS: We conducted a population-based case-control study of several selected major birth defects using data from the Atlanta Birth Defects Risk Factor Surveillance Study. Mothers who delivered an infant with and without selected birth defects in a 5-county metropolitan Atlanta area between January 1993 and August 1997 were interviewed. Maternal body mass index (BMI) was calculated from self-reported maternal prepregnancy weight and height. Women with known preexisting diabetes were excluded. The risks for obese women (BMI > or =30) and overweight women (BMI 25.0-29.9) were compared with those for average-weight women (BMI 18.5-24.9). RESULTS: Obese women were more likely than average-weight women to have an infant with spina bifida (unadjusted odds ratio [OR]: 3.5; 95% confidence interval [CI]: 1.2-10.3), omphalocele (OR: 3.3; 95% CI: 1.0-10.3), heart defects (OR: 2.0; 95% CI: 1.2-3.4), and multiple anomalies (OR: 2.0; 95% CI: 1.0-3.8). Overweight women were more likely than average-weight women to have infants with heart defects (OR: 2.0; 95% CI: 1.2-3.1) and multiple anomalies (OR: 1.9; 95% CI: 1.1-3.4). CONCLUSIONS: Our study confirmed the previously established association between spina bifida and prepregnancy maternal obesity and found an association for omphalocele, heart defects, and multiple anomalies among infants of obese women. We also found an association between heart defects and multiple anomalies and being overweight before pregnancy. A higher risk for some birth defects is yet another adverse pregnancy outcome associated with maternal obesity. Obesity prevention efforts are needed to increase the number of women who are of healthy weight before pregnancy.