Além das curvas de crescimento: investigando o atendimento pediátrico e as práticas de puericultura na formação em residências médicas / Beyond growth curves: investigating service pediatric care and childcare practices in training in medical residencies

Este Trabalho de Conclusão de Curso (TCC) investiga a prática da puericultura e o atendimento pediátrico por residentes, com foco no aprendizado, confiança e atualizações dos profissionais, proporcionados pelos programas de residência médica. Os resultados revelam que a atualização é crucial para garantir a qualidade do atendimento, considerando as constantes evoluções na área pediátrica. Aspectos como crescimento, desenvolvimento neuropsicomotor, vacinação, diário alimentar e dinâmica familiar são fundamentais na consulta de puericultura e a conscientização sobre a importância da vacinação também é relevante. Promover programas de residência médica com formação teórica sólida e baseada em evidências científicas é essencial para o desenvolvimento de profissionais preparados para uma prática pediátrica de excelência, beneficiando diretamente a saúde das crianças e adolescentes atendidos. Palavras-chave: Medicina baseada em evidências. Puericultura. Hospitais de Ensino. Pediatria. Residência médica.

Socioeconomic and geographic inequities in vaccination among children 12 to 59 months in Mexico, 2012 to 2021 / Inequidades socioeconómicas y geográficas en la vacunación infantil entre los 12 y 59 meses de edad, México, 2012-2021 / Iniquidades socioeconômicas e geográficas na vacinação de crianças entre 12 e 59 meses no México, 2012 a 2021

ABSTRACT Objective. To document the evolution of socioeconomic and geographical inequalities in childhood vaccination in Mexico from 2012 to 2021. Methods. Repeated cross-sectional analysis using three rounds of National Health and Nutrition Surveys (2012, 2018, and 2021). Dichotomous variables were created to identify the proportion of children who received no dose of each vaccine included in the national immunization schedule (BCG; diphtheria, pertussis, and tetanus-containing; rotavirus; pneumococcal conjugate; and measles, mumps, and rubella [MMR]), and the proportion completely unvaccinated. The distribution of unvaccinated children was analyzed by state, and by socioeconomic status using the concentration index. Results. The prevalence of completely unvaccinated children in Mexico was low, with 0.3% children in 2012 and 0.8% children in 2021 receiving no vaccines (p = 0.070). Notwithstanding, for each vaccine, an important proportion of children missed receiving any dose. Notably, the prevalence of MMR unvaccinated children was 10.2% (95% CI 9.2-11.1) in 2012, 22.3% (95% CI 20.9-23.8) in 2018, and 29.1% (95% CI 26.3-31.8) in 2021 (p < 0.001 for the difference between 2012 and 2021). The concentration index indicated pro-rich inequalities in non-vaccination for 2 of 5 vaccines in 2012, 3 of 5 vaccines in 2018, and 4 of 5 vaccines in 2021. There were marked subnational variations. The percentage of MMR unvaccinated children ranged from 3.3% to 17.9% in 2012, 5.5% to 36.5% in 2018, and 13.1% to 72.5% in 2021 across the 32 states of Mexico. Conclusions. Equitable access to basic childhood vaccines in Mexico has deteriorated over the past decade. Vigilant equity monitoring coupled with tailored strategies to reach those left out is urgently required.

RESUMEN Objetivo. Documentar la evolución de las inequidades socioeconómicas y geográficas en la vacunación infantil en México del 2012 al 2021. Métodos. Se llevó a cabo un análisis transversal repetido con tres rondas (2012, 2018 y 2021) de la Encuesta Nacional de Salud y Nutrición (ENSANUT). Se crearon variables dicotómicas para determinar la proporción de la población infantil que no había recibido cada una de las vacunas incluidas en el calendario nacional de vacunación (BCG; difteria, tos ferina y tétanos; rotavirus; conjugado neumocócico; y sarampión, parotiditis y rubéola [triple viral]) y la proporción de la población infantil completamente sin vacunar. La distribución de la población infantil sin vacunar se analizó por estado y nivel socioeconómico mediante el índice de concentración. Resultados. La prevalencia de la población infantil completamente sin vacunar en México fue baja, con 0,3% en el 2012 y 0,8% en el 2021 de la población infantil que no recibió ninguna vacuna (p = 0,070). No obstante, en relación con cada vacuna, una gran proporción de población infantil no recibió ninguna dosis. En particular, la prevalencia de la población infantil sin vacunarse con la triple viral fue de 10,2% (IC del 95% 9,2-11,1) en el 2012, 22,3% (IC del 95% 20,9-23,8) en el 2018 y 29,1% (IC del 95 % 26,3-31,8) en el 2021 (p < 0,001 para la diferencia entre el 2012 y el 2021). El índice de concentración reveló desigualdades que favorecen a los estratos más ricos en la probabilidad de no estar vacunado para 2 de las 5 vacunas en 2012, en 3 de las 5 vacunas en 2018, y en 4 de las 5 vacunas en el 2021. Asimismo, hubo marcadas variaciones subnacionales: el porcentaje de la población infantil que no recibió la vacuna triple viral osciló entre 3,3% y 17,9% en el 2012, entre 5,5% y 36,5% en el 2018 y entre 13,1% y 72,5% en el 2021 en los 32 estados de México. Conclusiones. El acceso equitativo a las vacunas infantiles básicas en México se ha deteriorado en el último decenio. Es urgentemente necesario un monitoreo vigilante de la equidad, así como estrategias adaptadas, para poder vacunar a la población al margen.

RESUMO Objetivo. Documentar a evolução das desigualdades socioeconômicas e geográficas na vacinação infantil no México, no período entre 2012 e 2021. Métodos. Foi realizada a análise repetida de dados transversais obtidos em três ciclos da Pesquisa Nacional de Saúde e Nutrição do México (2012, 2018 e 2021). Variáveis dicotômicas foram elaboradas para estimar o percentual de crianças que não receberam nenhuma dose de cada uma das vacinas do calendário nacional de vacinação (a saber: vacina BCG, vacina contra difteria, coqueluche e tétano, vacina contra rotavírus, vacina pneumocócica conjugada e vacina contra sarampo, caxumba e rubéola [SCR]) e a proporção de crianças totalmente não vacinadas. O índice de concentração foi usado para analisar a distribuição das crianças não vacinadas por estado e condição socioeconômica. Resultados. A prevalência de crianças totalmente não vacinadas foi baixa no país (0,3% em 2012 e 0,8% em 2021, p = 0,070). Porém, um percentual significativo deixou de receber alguma dose de vacina. A prevalência de crianças não vacinadas com a vacina SCR foi 10,2% (IC 95% 9,2-11,1) em 2012, 22,3% (IC 95% 20,9-23,8) em 2018 e 29,1% (IC 95% 26,3-31,8) em 2021 (p < 0,001 para a diferença entre 2012 e 2021). O índice de concentração indicou desigualdade de renda entre vacinados e não vacinados com relação a 2 das 5 vacinas em 2012, 3 das 5 vacinas em 2018 e 4 das 5 vacinas em 2021. Houve uma grande variação geográfica na vacinação infantil. Em particular, o percentual de não vacinados com a vacina SCR nos 32 estados do país variou de 3,3% a 17,9% em 2012, 5,5% a 36,5% em 2018 e 13,1% a 72,5% em 2021. Conclusões. Ocorreu uma piora no acesso equitativo à vacinação básica infantil na última década no México. É imprescindível monitorar atentamente a equidade e implementar estratégias específicas para garantir a cobertura vacinal de todos.

Vacunacion antirrábica en caninos y felinos de la Ciudad de Buenos Aires: Año 2021 / Rabies vaccination in Buenos Aires City: Year 2021

El objetivo del presente informe es exponer la situación actual de la vacunación antirrábica de la Ciudad de Buenos Aires, con el fin de realizar una planificación estratégica de prevención y control de la enfermedad. Se utilizaron datos sobre vacunación realizada por veterinarias privadas estimados a partir de la venta de talonarios por parte del Consejo Profesional de Médicos Veterinarios (CPMV); así como la vacunación realizada por los efectores públicos de salud: Instituto de Zoonosis Luis Pasteur (IZLP) y Mascotas de la Ciudad (MC).

Health Care System View of Human Papilloma Virus (HPV) Vaccine Acceptability by Emirati Men.

This is the most frequent sexually transmitted illness on the planet, and both men and women are equally vulnerable. HPV is associated with a broad variety of female disorders, including 99 percent of all cervical cancer cases. Specifically, the goal and contributions of this study are to determine Emirati men's opinions about the HPV vaccination, specifically whether they would use it themselves or allow their female relatives to use the vaccine. To collect the primary data, a statistical cross-sectional survey was conducted. This quantitative study was conducted using primary sources of data. A questionnaire survey with a sample size of 390 participants was used to collect data from 400 individuals. Male university students in the United Arab Emirati men have a weak grasp of HPV and are averse to vaccination (Ortashi et al., 2013). The percentage of Emirati men who accept the HPV vaccination is 37%. A total of 40.3% of the respondents opted not to participate in the survey at all. Eighty-six percent of the women surveyed had heard of cervical cancer, and one-third believed that they were at risk in the future. Twenty-five percent of those surveyed said that the HPV vaccination was safe, while 26% said it was unsafe. Respondents were just 3.1 percent vaccinated, and their family members were only 87% not vaccinated.

Effectiveness of Hepatitis B Vaccination Campaign in Italy: Towards the Control of HBV Infection for the First Time in a European Country.

BACKGROUND: In 1991, a mass immunization campaign against the hepatitis B virus (HBV) for children and teenagers was introduced in Italy. This study evaluated the impact of the immunization campaign on the incidence and modes of HBV transmission. METHOD: Acute HBV cases of viral hepatitis were reported to the National Surveillance System (SEIEVA). Hepatitis A cases reported to the same system were used as controls to calculate the adjusted odds ratios and the population attributable risk for potential risk factors. RESULTS: The incidence of acute HBV declined from 5.0 in 1990 to 0.4 in 2019 per 100,000 population. The fall was almost total in people targeted by the campaign: in 2019, zero cases (100% reduction) in the age-group 0-14 years and 0.1 cases per 100,000 population (99.4% reduction) in the age-group 15-24 years were reported. In the decade 2010-2019, nearly one-fifth (19.3%) of cases occurred in foreigners. Intravenous drug use is no longer a risk factor (OR = 0.7; 95% CI = 0.5-1.02). Beauty treatments, risky sexual exposure, and household contact with an HBsAg carrier were found to be independent predictors of acute hepatitis B. CONCLUSIONS: The HB vaccination campaign proved effective in minimising acute HBV in Italy. Control of the infection is close to being reached for the first time in Europe.

Uptake of infant and preschool immunisations in Scotland and England during the COVID-19 pandemic: An observational study of routinely collected data.

BACKGROUND: In 2020, the SARS-CoV-2 (COVID-19) pandemic and lockdown control measures threatened to disrupt routine childhood immunisation programmes with early reports suggesting uptake would fall. In response, public health bodies in Scotland and England collected national data for childhood immunisations on a weekly or monthly basis to allow for rapid analysis of trends. The aim of this study was to use these data to assess the impact of different phases of the pandemic on infant and preschool immunisation uptake rates. METHODS AND FINDINGS: We conducted an observational study using routinely collected data for the year prior to the pandemic (2019) and immediately before (22 January to March 2020), during (23 March to 26 July), and after (27 July to 4 October) the first UK "lockdown". Data were obtained for Scotland from the Public Health Scotland "COVID19 wider impacts on the health care system" dashboard and for England from ImmForm. Five vaccinations delivered at different ages were evaluated; 3 doses of "6-in-1" diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, and hepatitis B vaccine (DTaP/IPV/Hib/HepB) and 2 doses of measles, mumps, and rubella (MMR) vaccine. This represented 439,754 invitations to be vaccinated in Scotland and 4.1 million for England. Uptake during the 2020 periods was compared to the previous year (2019) using binary logistic regression analysis. For Scotland, uptake within 4 weeks of a child becoming eligible by age was analysed along with geographical region and indices of deprivation. For Scotland and England, we assessed whether immunisations were up-to-date at approximately 6 months (all doses 6-in-1) and 16 to 18 months (first MMR) of age. We found that uptake within 4 weeks of eligibility in Scotland for all the 5 vaccines was higher during lockdown than in 2019. Differences ranged from 1.3% for first dose 6-in-1 vaccine (95.3 versus 94%, odds ratio [OR] compared to 2019 1.28, 95% confidence intervals [CIs] 1.18 to 1.39) to 14.3% for second MMR dose (66.1 versus 51.8%, OR compared to 2019 1.8, 95% CI 1.74 to 1.87). Significant increases in uptake were seen across all deprivation levels. In England, fewer children due to receive their immunisations during the lockdown period were up to date at 6 months (6-in-1) or 18 months (first dose MMR). The fall in percentage uptake ranged from 0.5% for first 6-in-1 (95.8 versus 96.3%, OR compared to 2019 0.89, 95% CI 0.86- to 0.91) to 2.1% for third 6-in-1 (86.6 versus 88.7%, OR compared to 2019 0.82, 95% CI 0.81 to 0.83). The use of routinely collected data used in this study was a limiting factor as detailed information on potential confounding factors were not available and we were unable to eliminate the possibility of seasonal trends in immunisation uptake. CONCLUSIONS: In this study, we observed that the national lockdown in Scotland was associated with an increase in timely childhood immunisation uptake; however, in England, uptake fell slightly. Reasons for the improved uptake in Scotland may include active measures taken to promote immunisation at local and national levels during this period and should be explored further. Promoting immunisation uptake and addressing potential vaccine hesitancy is particularly important given the ongoing pandemic and COVID-19 vaccination campaigns.

Cobertura vacinal contra influenza em gestantes da região Sudeste do Brasil: análise de 2010­2020 / Influenza vaccination coverage in pregnant women in the Southeast region of Brazil: analysis from 2010 to 2020

Objetivo: Analisar a cobertura vacinal contra a influenza em gestantes na região Sudeste do Brasil, nos anos de 2010 a 2020. Métodos:Estudo ecológico, de série temporal, realizado com dados do Sistema de Informação do Programa Nacional de Imunizações (SI-PNI), referentes aos registros de doses da vacina contra influenza em gestantes no estado de Minas Gerais. Resultados: A cobertura vacinal adequada foi alcançada em apenas quatro dos 11 anos estudados, variando de 49,75% em 2011 a 88,5% em 2015. No ano de 2020 foi alcançado 80,82%. Possíveis determinantes são discutidos em uma perspectiva ampliada, que pode subsidiar planejamento de ações em todo o país. Conclusão: A cobertura vacinal contra Influenza nas gestantes apresentou, em sua maior parte, uma tendência estacionária, apontando para a possível necessidade de educação permanente dos profissionais de saúde envolvidos no pré-natal, qualificação de suas ações na área de educação em saúde para esclarecer dúvidas das gestantes sobre a temática.

Objective: To analyze the influenza vaccination coverage in pregnant women in the Southeast region of Brazil between years 2010 and 2020. Methods: An ecological, time series study conducted with data from the National Immunization Program Information System (SI-PNI) referring to records of doses of influenza vaccine in pregnant women in the state of Minas Gerais. Results:Adequate vaccination coverage was achieved in only four out of the 11 years studied, ranging from 49.75% in 2011 to 88.5% in 2015. In 2020, the rate of 80.82% was reached. Possible determinants are discussed in an expanded perspective that can support the planning of actions across the country. Conclusion: Influenza vaccination coverage in pregnant women showed a stagnation trend for the most part, pointing to the possible need for continuing education of health professionals involved in antenatal care and qualification of their actions in the area of health education to clarify pregnant women's doubts on the subject.

Impact of the SARS-CoV-2 pandemic on routine immunisation services: evidence of disruption and recovery from 170 countries and territories.

BACKGROUND: The SARS-CoV-2 pandemic has revealed the vulnerability of immunisation systems worldwide, although the scale of these disruptions has not been described at a global level. This study aims to assess the impact of COVID-19 on routine immunisation using triangulated data from global, country-based, and individual-reported sources obtained during the pandemic period. METHODS: This report synthesised data from 170 countries and territories. Data sources included administered vaccine-dose data from January to December, 2019, and January to December, 2020, WHO regional office reports, and a WHO-led pulse survey administered in April, 2020, and June, 2020. Results were expressed as frequencies and proportions of respondents or reporting countries. Data on vaccine doses administered were weighted by the population of surviving infants per country. FINDINGS: A decline in the number of administered doses of diphtheria-pertussis-tetanus-containing vaccine (DTP3) and first dose of measles-containing vaccine (MCV1) in the first half of 2020 was noted. The lowest number of vaccine doses administered was observed in April, 2020, when 33% fewer DTP3 doses were administered globally, ranging from 9% in the WHO African region to 57% in the South-East Asia region. Recovery of vaccinations began by June, 2020, and continued into late 2020. WHO regional offices reported substantial disruption to routine vaccination sessions in April, 2020, related to interrupted vaccination demand and supply, including reduced availability of the health workforce. Pulse survey analysis revealed that 45 (69%) of 65 countries showed disruption in outreach services compared with 27 (44%) of 62 countries with disrupted fixed-post immunisation services. INTERPRETATION: The marked magnitude and global scale of immunisation disruption evokes the dangers of vaccine-preventable disease outbreaks in the future. Trends indicating partial resumption of services highlight the urgent need for ongoing assessment of recovery, catch-up vaccination strategy implementation for vulnerable populations, and ensuring vaccine coverage equity and health system resilience. FUNDING: US Agency for International Development.

Association of the COVID-19 Pandemic With Routine Childhood Vaccination Rates and Proportion Up to Date With Vaccinations Across 8 US Health Systems in the Vaccine Safety Datalink.

Importance: The COVID-19 pandemic has affected routine vaccine delivery in the US and globally. The magnitude of these disruptions and their association with childhood vaccination coverage are unclear. Objectives: To compare trends in pediatric vaccination before and during the pandemic and to evaluate the proportion of children up to date (UTD) with vaccinations by age, race, and ethnicity. Design, Setting, and Participants: This surveillance study used a prepandemic-postpandemic control design with data from 8 health systems in California, Oregon, Washington, Colorado, Minnesota, and Wisconsin in the Vaccine Safety Datalink. Children from age groups younger than 24 months and 4 to 6, 11 to 13, and 16 to 18 years were included if they had at least 1 week of health system enrollment from January 5, 2020, through October 3, 2020, over periods before the US COVID-19 pandemic (January 5, 2020, through March 14, 2020), during age-limited preventive care (March 15, 2020, through May 16, 2020), and during expanded primary care (May 17, 2020, through October 3, 2020). These individuals were compared with those enrolled during analogous weeks in 2019. Exposures: This study evaluated UTD status among children reaching specific ages in February, May, and September 2020, compared with those reaching these ages in 2019. Main Outcomes and Measures: Weekly vaccination rates for routine age-specific vaccines and the proportion of children UTD for all age-specific recommended vaccines. Results: Of 1 399 708 children in 2019 and 1 402 227 in 2020, 1 371 718 were female (49.0%) and 1 429 979 were male (51.0%); 334 216 Asian individuals (11.9%), 900 226 were Hispanic individuals (32.1%), and 201 619 non-Hispanic Black individuals (7.2%). Compared with the prepandemic period and 2019, the age-limited preventive care period was associated with lower weekly vaccination rates, with ratios of rate ratios of 0.82 (95% CI, 0.80-0.85) among those younger than 24 months, 0.18 (95% CI, 0.16-0.20) among those aged 4 to 6 years, 0.16 (95% CI, 0.14-0.17) among those aged 11 to 13 years, and 0.10 (95% CI, 0.08-0.13) among those aged 16 to 18 years. Vaccination rates during expanded primary care remained lower for most ages (ratios of rate ratios: <24 months, 0.96 [95% CI, 0.93-0.98]; 11-13 years, 0.81 [95% CI, 0.76-0.86]; 16-18 years, 0.57 [95% CI, 0.51-0.63]). In September 2020, 74% (95% CI, 73%-76%) of infants aged 7 months and 57% (95% CI, 56%-58%) of infants aged 18 months were UTD vs 81% (95% CI, 80%-82%) and 61% (95% CI, 60%-62%), respectively, in September 2019. The proportion UTD was lowest in non-Hispanic Black children across most age groups, both during and prior to the COVID-19 pandemic (eg, in May 2019, 70% [95% CI, 64%-75%] of non-Hispanic Black infants aged 7 months were UTD vs 82% [95% CI, 81%-83%] in all infants aged 7 months combined). Conclusions and Relevance: As of September 2020, childhood vaccination rates and the proportion who were UTD remained lower than 2019 levels. Interventions are needed to promote catch-up vaccination, particularly in populations at risk for underimmunization.

Evaluation of the direct and indirect impact on pneumonia hospitalization after almost a decade of the 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine in Brazil

Introduction: Pneumococcal pneumonia is a leading cause of severe disease, leading to approximately 2.2 million hospital admissions in 2019 in Brazil. Since 2010, the 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine was introduced in Brazil, as part of the National Immunization Program (NIP) with universal access, approximated coverage of 91.4% in 2019. Although studies from many countries are available, there is still a need to understand the effect of the vaccine introduction on the incidence of pneumonia hospitalizations in Brazil.Methods: Data on hospitalization associated with the diagnosis of pneumonia in the population assisted by the Brazilian Public Health System were accessed to fit a time series analysis, which tested the main hypothesis of the influence of vaccination on the trends for the incidence of pneumonia hospitalizations.Results: The post-vaccination period showed a negative trend, reducing 1.75, 0.16, and 0.11 cases per 100,000 inhabitants per month for the groups < 1, 1­4, and 5­9 years old, respectively. In individuals older than 20 years, the post-vaccination period has a positive trend, but not as great as compared trends before the vaccination period. These results indicate a protective herd effect in the older population, nine years after introducing the pneumococcal vaccine in the NIP.Conclusion: Vaccination with pneumococcal conjugated vaccine reduces hospitalizations associated with pneumonia diagnosis in vaccinated and non-vaccinated populations in a sustained and progressive manner.

Experiencia chilena en el comportamiento del SARS-COV-2 y campaña de vacunación en pediatría / Chilean experience in the behavior of SARS-COV-2 and the vaccination in pediatrics

La pandemia por Covid-19 ha provocado millones de hospitalizaciones y muertes en el mundo, principalmente en la población adulta. A pesar de que la población pediátrica se ha visto afectada con una menor frecuencia y severidad que los adultos, no están exentos de casos prolongados, graves y letalidad, destacando la aparición de un nuevo cuadro clínico, como el síndrome inflamatorio multisistémico asociado a Covid-19. Constantes esfuerzos científicos han permitido avanzar de manera efectiva en la implementación de estrategias de vacunación pediátrica masiva contra el Covid-19. Actualmente, en Chile esta estrategia está demostrando ser segura, efectiva y puede colaborar con la reapertura de escuelas y el regreso a clases presenciales, de manera de disminuir las interrupciones y brechas escolares, otorgando otros beneficios indirectos, tales como el mejoramiento de la salud mental y emocional, el incremento de la actividad física y estabilidad familiar, aportando en el mejoramiento del bienestar y calidad de vida de los niños y sus familias.

The Covid-19 pandemic has caused millions of hospitalizations and deaths in the world, mainly in the adult population. Although the pediatric population has been affected less frequently and less severely than adults, they are not exempt from prolonged, severe cases and lethality by SARS-CoV-2, highlighting the appearance of a new clinical picture, such as multisystem inflammatory syndrome associated with Covid-19. Constant scientific efforts have made it possible to effectively advance in the implementation of mass pediatric vaccination strategies against Covid-19. Currently, in Chile this strategy is proving to be safe, effective and can collaborate with the school openings and returning to presential classes, to reduce interruptions and school-gaps, granting other indirect benefits, such as the improvement of mental and emotional health, the increase of physical activity and family stability, contributing to the improvement of the well-being and quality of life of children and their families.

Vacunación contra COVID-19 y salud digital

Los registros electrónicos de inmunizaciones forman parte esencial de los sistemas de información para la salud, tanto para su integración con la historia clínica de los ciudadanos, como para las intervenciones de salud pública para la prevención y control de enfermedades. En el marco de la introducción de la vacuna contra COVID-19, se presenta una importante oportunidad para dar un salto a la transformación digital para aquellos países que no cuentan con un sistema de información electrónico para inmunizaciones, y de fortalecimiento para aquellos que ya cuentan con uno pero requiere una actualización e incorporación de nuevas funcionalidades que lo hagan más robusto.

Progress in reaching unvaccinated (zero-dose) children in India, 1992-2016: a multilevel, geospatial analysis of repeated cross-sectional surveys.

BACKGROUND: Reaching zero-dose children (infants who receive no routine vaccinations) is a global strategic priority. We studied zero-dose children in India over 24 years to clarify aggregate trends and the contribution of large-scale social, economic, and geographical inequalities to these. METHODS: We did a multilevel, geospatial analysis of repeated cross-sectional surveys of all four rounds (1992-2016) of India's National Family Health Survey to study the prevalence, distribution, and drivers of zero-dose (no first dose of diphtheria, tetanus, and pertussis) vaccination status. We included all children born to participating women who were aged 12-23 months at the time of the survey, as this is the standard age at which immunisation data are assessed. Children who died before the survey and those missing data on key outcomes or correlates were excluded. The outcome was child zero-dose vaccination status. We also compared the prevalence of nutritional deficits among zero-dose versus vaccinated children. For the most recent survey, we produced geospatial estimates identifying the prevalence of zero-dose children across states and districts and used these to project head count. FINDINGS: We examined 393 167 children for eligibility. 72 848 children were included in the final analytic data set. The proportion of zero-dose children in India declined from 33·4% (95% CI 32·5-34·2) in 1992 to 10·1% (9·8-10·4) in 2016. Progress notwithstanding, in 2016, zero-dose children remained concentrated among disadvantaged groups (prevalence in the bottom wealth quintile 15·3%, 95% CI 14·6-16·0; prevalence among mothers with no education 16·8%, 16·1-17·4). Compared with vaccinated children, zero-dose children were more likely to suffer from malnutrition in all survey rounds (prevalence of severe stunting in 1992: zero dose 41·3%, 95% CI 39·2-43·8 vs vaccinated 28·5%, 27·2-29·7; 2016: zero dose 24·9%, 23·6-26·2 vs vaccinated 18·7%, 18·3-19·1). In 2016, there were an estimated 2·88 (95% CI 2·86-2·89) million zero-dose children in India, concentrated in less developed states and districts and several urban areas. INTERPRETATION: Over a 24-year period in India, child zero-dose status was shaped by large-scale social inequalities and remained a consistent marker of generalised vulnerability. Interventions that address this cycle of intergenerational inequities should be prioritised. FUNDING: None. TRANSLATIONS: For the French, Spanish, and Hindi translations of the abstract see Supplementary Materials section.

A snapshot of the practicality and barriers to COVID-19 interventions: Public health and healthcare workers' perceptions in high and low- and middle-income countries.

BACKGROUND: In response to the COVID-19 pandemic, governments have implemented a range of non-pharmaceutical interventions (NPIs) and pharmaceutical interventions (PIs) to reduce transmission and minimise morbidity and mortality, whilst maintaining social and economic activities. The perceptions of public health workers (PHWs) and healthcare workers (HCWs) are essential to inform future COVID-19 strategies as they are viewed as trusted sources and are at the forefront of COVID-19 response. The objectives of this study were to 1) describe the practicality of implementing NPIs and PIs and 2) identify potential barriers to implementation, as perceived by HCWs and PHWs. METHODS: We conducted a cross-sectional study of PHWs and HCWs perceptions of the implementation, practicality of, and barriers to implementation of NPIs and PIs using an online survey (28/9/2020-1/11/2020) available in English, French and Portuguese. We used descriptive statistics and thematic analysis to analyse quantitative and qualitative responses. RESULTS: In total, 226 respondents (67 HCWs and 159 PHWs) from 52 countries completed the survey and 222 were included in the final analysis. Participants from low and middle-income countries (LMICs) accounted for 63% of HCWs and 67% of PHWs, with the remaining from high-income (HICs). There was little difference between the perceptions of PHWs and HCWs in HICs and LMICs, with the majority regarding a number of common NPIs as difficult to implement. However, PHWs in HICs perceived restrictions on schools and educational institutions to be more difficult to implement, with a lack of childcare support identified as the main barrier. Additionally, most contact tracing methods were perceived to be more difficult to implement in HICs than LMICs, with a range of barriers reported. A lack of public support was the most commonly reported barrier to NPIs overall across both country income and professional groups. Similarly, public fear of vaccine safety and lack of vaccine supply were the main reported barriers to implementing a COVID-19 vaccine. However, PHWs and HCWs in LMICs perceived a lack of financial support and the vaccine being manufactured in another country as additional barriers. CONCLUSION: This snapshot provides insight into the difficulty of implementing interventions as perceived by PHWs and HCWs. There is no one-size-fits-all solution to implementing interventions, and barriers in different contexts do vary. Barriers to implementing a vaccine programme expressed here by HCWs and PHCWs have subsequently come to the fore internationally.

Will Americans Get Vaccinated? Predicting COVID-19 Vaccine Uptake Rates Under Contingent Scenarios.

OBJECTIVES: Amid a pandemic, vaccines represent a promising solution for mitigating public health and economic crises, and an improved understanding of individuals' vaccination intentions is crucial to design optimal immunization campaigns. This study predicts uptake rates for different COVID-19 vaccine specifications and identifies personal characteristics that moderate an individual's responsiveness to vaccine attributes. METHODS: We developed an online survey with contingent specifications of a COVID-19 vaccine, varying in effectiveness, risks of side effects, duration of immunity, and out-of-pocket cost. Using population-averaged logit models, we estimated vaccine uptake rates that account for uncertainty, heterogeneity across respondents, and interactions between vaccine and personal characteristics. RESULTS: We obtained 3047 completed surveys. The highest uptake rate for an annual vaccine, 62%, is predicted when vaccine effectiveness is 80% to 90%, side effects are minimal, and the vaccine is provided at zero cost, with decreases seen in the uptake rate for less effective vaccines, for example, 50% for 50% to 60% effectiveness. Moreover, we found that Americans' response to vaccine effectiveness depends on their self-reported concern, that is, concerned respondents report a higher willingness to get vaccinated. Our findings also indicate that COVID-19 vaccine uptake rates decrease with vaccine cost and that responsiveness to vaccine cost is moderated by income. CONCLUSIONS: Although providing the COVID-19 vaccine at zero cost will motivate many individuals to get vaccinated, a policy focused exclusively on vaccine cost may not be enough to reach herd immunity thresholds. Although those concerned with COVID-19 will participate, further evidence is needed on how to incentivize participation among the unconcerned (43%) to prevent further pandemic spread.