Are children on track with their routine immunization schedule in a fragile and protracted conflict state of South Sudan? A community-based cross-sectional study.

OBJECTIVES: The objective of this study was to assess if children aged 0-23 months in a conflict-affected state of South Sudan were on track with their immunization schedule and to identify predisposing factors that affected this study population from being on track with their routine immunization schedule. DESIGN: Community-based cross-sectional study using a semi-structured questionnaire. The binary outcome of interest was defined as being on or off track with routine vaccination schedule. Multivariable logistic regression was used to analyze for the association between the predisposing factors surveyed and being off track with one's routine immunization schedule. SETTING: Rural communities in four counties (Rumbek Center, Rumbek North, Rumbek East and Wulu) of the Western Lakes state in South Sudan during January 10, 2020 to June 10, 2020. PARTICIPANTS: We surveyed 428 children aged 0-23 months and their mothers/caregivers who lived in either of the four counties in the Western Lakes State. Participants were selected using random ballot sampling. RESULTS: More than three-quarters of the children surveyed (75.5%) were off track with their vaccination schedule. Children with an immunization card had 71% reduced odds of being off track with their immunization (AOR = 0.29; 95% CI 0.10-0.83, p-value = 0.021) compared to children without immunization cards. Children who reside near health facilities and do not require transportation to facilities had 87% reduced odds of being off track with their immunization compared to those who lived far and required transport to facilities. Giving an adequate immunization notice before conducting immunization outreach visits to communities was also associated with reduced odds (AOR = 0.27; 95% CI 0.09-0.78. p-value = 0.016) of children being off track with their immunization. CONCLUSION: This study revealed that most children were off track with their vaccination schedule in South Sudan, which is not only influenced by maternal characteristics but mainly by community- and state-level immunization service delivery mechanisms. Policies and interventions to improve child immunization uptake should prioritize these contextual characteristics.

Geographical variations and associated factors of defaulting from immunization among children aged 12 to 23 months in Ethiopia: using spatial and multilevel analysis of 2016 Ethiopian Demographic and Health Survey.

BACKGROUND: In Ethiopia, despite the considerable improvement in immunization coverage, the burden of defaulting from immunization among children is still high with marked variation among regions. However, the geographical variation and contextual factors of defaulting from immunization were poorly understood. Hence, this study aimed to identify the spatial pattern and associated factors of defaulting from immunization. METHODS: An in-depth analysis of the 2016 Ethiopian Demographic and Health Survey (EDHS 2016) data was used. A total of 1638 children nested in 552 enumeration areas (EAs) were included in the analysis. Global Moran's I statistic and Bernoulli purely spatial scan statistics were employed to identify geographical patterns and detect spatial clusters of defaulting immunization, respectively. Multilevel logistic regression models were fitted to identify factors associated with defaulting immunization. A p value < 0.05 was used to identify significantly associated factors with defaulting of child immunization. RESULTS: A spatial heterogeneity of defaulting from immunization was observed (Global Moran's I = 0.386379, p value < 0.001), and four significant SaTScan clusters of areas with high defaulting from immunization were detected. The most likely primary SaTScan cluster was seen in the Somali region, and secondary clusters were detected in (Afar, South Nation Nationality of people (SNNP), Oromiya, Amhara, and Gambella) regions. In the final model of the multilevel analysis, individual and community level factors accounted for 56.4% of the variance in the odds of defaulting immunization. Children from mothers who had no formal education (AOR = 4.23; 95% CI: 117, 15.78), and children living in Afar, Oromiya, Somali, SNNP, Gambella, and Harari regions had higher odds of having defaulted immunization from community level. CONCLUSIONS: A clustered pattern of areas with high default of immunization was observed in Ethiopia. Both the individual and community-level characteristics were statistically significant factors of defaulting immunization. Therefore, the Federal Ethiopian Ministry of Health should prioritize the areas with defaulting of immunization and consider the identified factors for immunization interventions.

Sociodemographic and health care factors in determining immunization defaulters among preschool children in Petaling District, Selangor: a cross-sectional study in Malaysia.

BACKGROUND: Immunization is an effective public health intervention to reduce morbidity and mortality among children and it will become more effective if the child can receive the full course of recommended immunization doses. The objective of this study was to determine the prevalence of childhood immunization defaulters and its associated factors among children below 5 years attending registered child care centers in Petaling District, Selangor. METHODS: This was a cross-sectional survey among mothers with children below 5 years from 60 registered child care centers in District of Petaling, Selangor. Data was collected by a self-administered questionnaire from a total of 1015 mothers. Simple Logistic Regression, Chi-square or Fisher's exact test were performed to determine the association between individual categorical variables and childhood immunization defaulters. Multivariate logistic regression was used to determine the predictors of childhood immunization defaulters. RESULTS: The study showed that the prevalence rate for defaulting immunization was 20.7%. After adjusting all confounders, six statistically significant predictors of childhood immunization defaulters were determined. They were non-Muslims (aOR = 1.669, 95% CI = 1.173, 2.377, p = 0.004), mothers with diploma and below educational background (aOR = 2.296, 95% CI = 1.460, 3.610, p < 0.0001), multiple children of 5 and above in a family (aOR = 2.656, 95% CI = 1.004, 7.029, p = 0.040), mothers with younger children aged 2 years and below (aOR = 1.700, 95% CI = 1.163, 2.486, p = 0.006), long travelling time of more than 30 min to the immunization health facility (aOR = 2.303, 95% CI = 1.474, 3.599, p < 0.0001) and had delayed at least one of the immunization schedule (aOR = 2.747, 95% CI = 1.918, 3.933, p < 0.0001). CONCLUSION: This study highlights the need of implementation of intervention programs should be intensified to improve the childhood immunization status, focusing on the Non-Muslim community, mothers with low educational level, mothers with multiple children and mothers with children aged 2 years and below. In light of the growing problem of immunization defaulters in Malaysian children, identifying mothers at risk of not completing their children immunization schedule and educating them is an important strategy to recurrent outbreaks of infectious disease in the country.

She knows that she will not come back: tracing patients and new thresholds of collective surveillance in PMTCT Option B.

BACKGROUND: Malawi, Uganda, and Zimbabwe have recently adopted a universal 'test-and-treat' approach to the prevention of mother-to-child transmission of HIV (Option B+). Amongst a largely asymptomatic population of women tested for HIV and immediately started on antiretroviral treatment (ART), a relatively high number are not retained in care; they are labelled 'defaulters' or 'lost-to-follow-up' patients. METHODS: We draw on data collected as part of a study looking at ART decentralization (Lablite) to reflect on the spaces created through the instrumentalization of community health workers (CHWs) for the purpose of bringing women who default from Option B+ back into care. Data were collected through semi-structured interviews with CHWs who are designated to trace Option B+ patients in Uganda, Malawi and Zimbabwe. FINDINGS: Lost to follow up women give a range of reasons for not coming back to health facilities and often implicitly choose not to be traced by providing a false address at enrolment. New strategies have sought to utilize CHWs' liminal positionality - situated between the experience of living with HIV, having established local social ties, and being a caretaker - in order to track 'defaulters'. CHWs are often deployed without adequate guidance or training to protect confidentiality and respect patients' choice. CONCLUSIONS: CHWs provide essential linkages between health services and patients; they embody the role of 'extension workers', a bridge between a novel health policy and 'non-compliant patients'. Option B+ offers a powerful narrative of the construction of a unilateral 'moral economy', which requires the full compliance of patients newly initiated on treatment.

Parental Awareness of the Preschool Orthoptics Visual Screening in Brunei-Muara District and Factors Contributing to Defaulters.

Background: The preschool orthoptics visual screening program began in Brunei Darussalam in 2004 to detect amblyopia, a common cause of treatable visual disorders in children. Amblyopia can be asymptomatic, easily missed, and cause permanent adverse visual consequences; hence, it is necessary to be screened. The parental role in ensuring timely visual screening is pivotal to their child's visual well-being and educational success. This study explored parental awareness and reasons for their nonattendance. Methods: A cross-sectional study of 401 parents was conducted in the Brunei-Muara district in private kindergarten schools and maternal and child health clinics. A self-designed and self-administered questionnaire was used. Data collected was analysed using RStudio in the form of descriptive and analytic statistics. Results: The study findings showed that 52.8% defaulted their screening and there was a significant association between parental awareness and the defaulters (p < 0.05). Only 39.9% of parents were aware of the screening service availability, and 50.1% had not taken their children for an eye check. The most significant sociodemographic factor that influenced awareness of the importance of vision screening was parental employment status (p = 0.013), revealing a 4.43 times higher likelihood of default if the father was unemployed. This study found that with each additional child, parents are 1.25 times less likely to seek eye screening (p < 0.05). Conclusions: The main reason for nonattendance was a lack of awareness of the situation and parents believed that their children were seeing well. Mitigating child visual screening defaults requires a community-focused approach.

Determinants of immunization defaulters among children aged 12-23 months in Ambo town, Oromia, Ethiopia: A case-control study.

Immunization is a public health intervention to reduce morbidity and mortality among children. However, vaccination becomes more effective if the child can receive the full course of recommended vaccination doses according to the schedule. Many children fail to complete the full course of vaccination. To identify the determinants of immunization defaulters among children aged 12-23 months in Ambo town, Oromia, Ethiopia. A community-based, unmatched, case-control study was done from October 1 to 25, 2021. A simple random sampling was used to select 317 (106 cases and 211 controls). Data were collected by using a pretested and structured questionnaire. Data were coded and entered to Epi-data version 3.1 and then transported to SPSS version 21.0 for statistical analysis. Descriptive analysis like frequency, mean, and percentage was calculated. Binary and multivariable logistic regression analysis was done. Finally, variables with a p value  < .05 were considered statistically significant. Urban residences (AOR = 0.288, 95% CI, 0.146, 570), government employee (AOR = 0.179, 95% CI, 0.057, 0.565), number of family members more than four (AOR = 2.696, 95% CI, 1.143, 6.358), higher income (AOR = 0.250, 95% CI, 0.099, 0.628), attending ANC (AOR = 0..237, 95% CI, 0.107, 0.525), and good awareness (AOR = 0.070, 95% CI, 0.005, 308) were significant predictors of immunization defaulters. This study has found that urban residences, government employee by occupation, number of family members more than four, higher monthly income, and attending ANC were identified as determinants of childhood immunization defaulters. Social Behavior Change intervention programs should focus on providing health information about the importance of the vaccine and vaccine schedule. Due attention should be given for rural residents and farmers who had limited access to information and are more prone to defaulting. Policy-makers should consider those identified factors while designing intervention programs to enhance vaccination coverage.

Cytomorphological findings in drug defaulters of tuberculous lymphadenitis.

Objectives: Tuberculosis (TB) is an important health problem specially in the developing countries. Although effective chemotherapy is available, compliance of patient is a major challenge. The aim of this study was to describe cytomorphological features of drug defaulters on lymph node on fine-needle aspiration cytology (FNAC) and compare it with newly diagnosed cases. Material and Methods: A cross-sectional study was done for a period of 18 months, in which all patients having tuberculous lymphadenitis were included after taking detailed history regarding previous anti-TB drug intake. Cytomorphological findings in drug defaulters were evaluated and compared with newly diagnosed cases. Results: There were a total of 150 cases with 120 newly diagnosed and 30 drug defaulters. Splintered epithelioid cell granuloma was seen in 40% of drug defaulters, while it was absent in case of newly diagnosed cases (P < 0.0001). Well-formed epithelioid cell granuloma was most commonly seen in newly diagnosed cases (65.83%) followed by poorly formed granuloma (26.67%). Another significant finding was distribution of eosinophils which were significantly high in case of drug defaulters (56.67%) (P < 0.0001). Conclusion: Cytomorphological findings can help in identification of the drug defaulters on FNAC and thus plan further line of treatment.

Enhancing Routine Childhood Vaccination Uptake in the Cape Metropolitan District, South Africa: Perspectives and Recommendations from Point-of-Care Vaccinators.

Vaccination, and particularly childhood vaccination, is widely acknowledged as one of the greatest public health interventions in history. Nevertheless, challenges exist that threaten the progress of childhood vaccination in many parts of the world. We investigated challenges to vaccination experienced by point-of-care vaccinators in the Cape Town Metropolitan District (Cape Metro), and reported on their current and proposed efforts to combat these challenges. Semi-structured interviews were conducted with 19 vaccinators in 16 purposively selected healthcare facilities in the Cape Metro from September to November 2019. Interviews were transcribed and analysed using thematic and narrative analysis methods. Challenges of both the demand and the supply side of routine vaccination were reported by the study participants, as were contextual challenges such as community safety issues. Defaulting was the most common challenge encountered, reported by 16 of the 19 participants. The use of computerized appointment systems, the enlistment of community health workers to track down defaulters, and the use of certificates to incentivize caregivers are part of the creative ways of mitigating some of the challenges encountered by these vaccinators. Their insightful recommendations can positively influence the landscape of childhood vaccination uptake in the Cape Metro and beyond if adapted and applied.

Why are missed opportunities for immunisation and immunisation defaulting among children indistinguishable?

The two major global immunization agenda framings (Missed Opportunity for Immunisation (MOI) vs. Immunisation Defaulting) are interchangeably and inappropriately used in public health research and practice, with flawed or misleading strategies recommended and adopted in various settings around the world. This is demonstrated by the fact that many opportunities to incorporate findings from immunization coverage research into policy are squandered. The ineffectiveness of inappropriate interventions based on biased evidence can discourage and mislead policymakers to make radical decisions by discretion. This may explain why low- and middle-income countries are unable to vaccinate 80% of their children; it also poses a global health risk to capable countries. The current guidelines and information on MOI and immunization defaulting appear insufficient, and a little clarification would help immunisation forerunners achieve measurable progress in ensuring good coverage, particularly in low- and middle-income countries. The purpose of this paper is to provide appropriate recommendations to address this issue in immunization practice. Optimistically, this will stimulate further discussions, streamline differences, and gear global immunization governance on the subject to achieve the target coverage in low- and middle-income countries by 2030.

Implementation and outcomes of a patient tracing programme for HIV in Trinidad and Tobago.

A patient tracing programme was implemented at an HIV clinic in Trinidad and Tobago to address the problem of defaulters from HIV care and non-adherence to antiretroviral treatment (ART). The study objective was to evaluate the implementation and outcomes of this programme conducted between April and September 2017. Using patient tracing contact methods, trained social workers attempted to contact 1058 patients lost to follow up (LTFU) between July 2016 and March 2017. Of the 1058 LTFU, 192 were ineligible: 27 (2.5%) were transferred to another clinic, 64 (6%) deceased, 35 (3.3%) hospitalised, 50 (4.7%) migrated and 16 (1.5%) incarcerated. Of the 866 eligible patients for patient tracing, 277 (32%) remained permanently LTFU and 589 (68%) were successfully contacted, re-engaged in care and received adherence counselling. Of the 589 who returned to care, 507 (86%) restarted ART. The three most common barriers reported among the 589 who were reengaged were 'forgetting their appointments' (20%), 'being too busy/work' (16%), and 'not wanting to be seen attending the HIV clinic' (12%). The study findings demonstrated the tracing programme as feasible for re-engaging those who are LTFU and highlighted barriers that can be addressed to further improve retention in HIV care among people living with HIV.

Survival Analysis of Treatment Defaulters among Tuberculosis Patients in Government Medical College and Hospital, Aurangabad.

CONTEXT: Tuberculosis (TB) patients who do not complete treatment pose a potential public health risk through disease reactivation, increased transmission, and development of drug resistance. AIMS: (1) To determine the duration TB patients stay in the treatment before defaulting. (2) Factors associated with defaulters who had been treated in Government Medical College and Hospital (GMCH), Aurangabad. SETTING AND DESIGN: The study was conducted at TB Unit of GMCH, Aurangabad, and community. This was a retrospective cohort study. MATERIALS AND METHODS: Based on record review of 440 bacteriological-confirmed TB patients enrolled in the TB Unit of GMCH, Aurangabad, in 2015 from January 1, to December 31, we collected information on potential risk factors of all confirmed cases by primary and secondary data. For survival analysis, outcome of interest was treatment defaulter. Kaplan-Meier curves, log-rank test, and Cox-proportional hazard regression analysis were used to model outcome of interest. STATISTICAL ANALYSIS USED: Statistical analysis is performed using SPSS version 17. RESULTS: Out of total 440 TB patients registered, 13 patients got defaulted in 2015. Overall mean time of default was 279 days, with 276 days for males against 279 days for females. Many patients interrupted treatment during continuation phase. Treatment defaulters had an association with gender, category at the initiation of treatment, HIV status, smoking, and alcohol consumption. CONCLUSION: Targeted intervention with the goal toward adherence in persons abusing smoking and alcohol is recommended. Necessary actions need to be initiated in the program to strengthen the follow-up of patients and to bring behavioral changes by proper counseling.

Health-Related Quality of Life (HRQoL) scores vary with treatment and may identify potential defaulters during treatment of tuberculosis.

INTRODUCTION: Nigeria ranks third among the 22 high-burden TB countries in the world. With the availability of effective treatment strategies, and more patients surviving the disease, assessment of Patient Reported Outcomes (PROs) has become imperative to assist with patient evaluation of measured outcomes and thus improve morbidity. Literature is scarce on assessment and impact of chemotherapy on Health-Related Quality of Life (HRQoL) for patients with tuberculosis. AIM: This study evaluates the variation in Health-Related Quality of Life (HRQoL) in pulmonary TB patients during the intensive phase of treatment. METHODS: We recruited patients with pulmonary TB (PTB), from 3 different TB clinics across Ife Ijesha Zone, Osun State, Nigeria. Consenting patients were administered Short Form-36 HRQoL questionnaire at recruitment and at the end of intensive phase of treatment. HRQoL scores were compared at these two-time points, the degrees of changes were calculated and relationships with some. Directly Observed Therapy-Short (DOTS) course outcome measures were obtained. Logistic regression was used to identify factors associated with greatest change in HRQoL scores. RESULTS: Of the 130 recruited patients, we analysed data for 126 patients who met the inclusion criteria. Mean age was 36.7(SD15.5). The overall mean HRQoL score obtained at enrolment was 43.18 (SD 17.2) and 60.22 (SD19.83) at end of 2 months; mean change =17.04 p<0.001). The least change was on the emotional well-being domain (mean change = 4.24, p=0.05). Predictor of significant change in HRQoL scores were previous history of TB, HIV status and TB severity, p<0.05 each. High physical functioning score was a strong predictor of defaulters (OR = 5.3; 95%CI: 2.11-9.05, p = 0.01). CONCLUSION: Emotional domain is least affected by PTB while younger patients with no physical impairment are more likely to default treatment. Various aspects of HRQoL can be a useful tool for patient's evaluation and outcome prediction.

How Non Consumers Differ from Consumers: A Qualitative Approach to Synthesize the Attributes of Iron Folic Acid End Users.

INTRODUCTION: Anaemia continues to be a major hurdle to achieve optimum health in Indian population context. Although government continues to promote Iron Folic Acid (IFA) supplementation as one of the key strategies to combat with burden of anaemia, the expected level of IFA consumption and subsequent anaemia reduction could not be achieved. This study tries to investigate those influences, concerns, experiences and behaviour from an end user perspective through a qualitative methodology which may affect the IFA consumption ambi-directionally. AIM: To explore and understand the several aspects related with anaemia and IFA supplementation with special emphasis to reveal the contributory factors behind low level of IFA consumption at consumer end. MATERIALS AND METHODS: A community based qualitative study was conducted in clusters identified through multileveled stratification from a state of central India. A conceptual construct was made in priory for this study. As the research question was related with policy, this study adapted a framework technique for making interview topic guides. Two consumers and two non consumers from each identified cluster were interviewed in depth. The data obtained through 160 in depth interviews (from 80 consumers and 80 non consumers) was utilized for thematic framework, linkage association and to typify the phenomenon. RESULTS: Ignorance, difficult intake, meaninglessness, misconceptions and discontentment with the system were the major dimensions (sub themes) associated with discontinuation. All these sub themes were further converged into major theme of informational discontinuity. Investigators further typified the users/non users into persistent user, potential defaulters, impending defaulters and absolute non users. CONCLUSION: Informational gap seems to be the fundamental factor behind sub optimum IFA consumption. On a policy perspective, all the attempts should be done to instigate arise felt need' among target groups for IFA consumption.

Treatment Outcome and Follow-up of Tuberculosis Patients Put on Directly Observed Treatment Short-course Under Rural Health Training Center, Paithan, Aurangabad in India.

BACKGROUND: Revised National Tuberculosis Control Program (RNTCP) was found successful in achieving its objectives; still there is concern of relapse cases and defaulters. AIM: The aim of this study is to know the treatment outcome, to assess the reasons for relapse, default, death of patient and to assess the follow-up status of tuberculosis (TB) patients put on directly observed treatment short-course (DOTS). SUBJECTS AND METHODS: This cross-sectional survey was conducted in 140 TB patients put on DOTS during year 2005-2007 under Rural Health Training Center, Paithan. The personal interview was carried out by an investigator with pre-tested questionnaire during month of July-August 2008. RESULTS: Out of total 140, 125 TB cases could be traced: Category I 48% (60/125), Category II 16% (20/125) and Category III 36% (45/125). Cure rate among Category I was calculated to be 61.7% (37/60). Defaulters were observed to be 18.3% (11/60), 25% (5/20) and 20% (9/45) among Category I, Category II and Category III respectively. Death rate was higher (5%) among patients of Category II. During the follow-up visit, 82.4% (103/125) were found to be alive while 17.6% (22/125) dead. A total of 18 deaths were related with TB and its sequelae. Around 20% (5/25) defaulted because of feeling of well-being. During the follow-up visit, 5.8% (6/103) were again put on DOTS. CONCLUSIONS: Defaulters were high in present study. The majority of patients left the treatment due to feeling well. This can be tackled by effective counseling. Higher percentage of the patients showed improvement in their weight after completion of DOTS treatment. More emphasis was to be given toward existing TB patients to get successful results of RNTCP.

Comparison of Directly Observed Treatment Short Course (DOTS) with Self-Administered Therapy in Pulmonary Tuberculosis in Udupi District of Southern India.

BACKGROUND: Directly observed treatment short course (DOTS) and self-administered therapy (SAT) are the treatment options available for tuberculosis (TB). Studies conducted worldwide have shown difference in treatment outcome with these two treatment modalities. AIM: The study was undertaken to compare treatment outcome of DOTS and SAT in patients of pulmonary TB taking SAT from a tertiary care hospital and DOTS from the DOTS centre of a government hospital. MATERIALS AND METHODS: It was a retrospective comparative study. The case record files of patients with pulmonary TB diagnosed from March 2011 to February 2012 were analysed as per the proforma. The sample size of patients was 150 (75 each from DOTS and SAT). RESULTS: The treatment outcome in DOTS group was cured 70.7%, treatment completed 1.3%, failure 5.3%, deaths 10.7%, defaulters 8% and transferred out 4% whereas in SAT group, cure was seen in 68% and 4% completed the treatment, 1.3% had treatment failure, and 26.7% were lost to follow up which included deaths, defaulters and those patients who switched over to other hospitals. The treatment success rate was similar (72%) in both groups. There was no statistically significant difference observed in the average weight gain at the end of treatment between the two groups. A total of 11 adverse drug reactions (4 DOTS, 7 SAT) were recorded in the study. CONCLUSION: The study shows no statistically significant difference between success rate in patients taking DOTS and SAT.

Clinical consequences of non-compliance with directly observed therapy short course (DOTS): Story of a recurrent defaulter.

In 1993, the World Health Organization (WHO) declared tuberculosis (TB) a global emergency, and subsequently introduced the directly observed therapy short course (DOTS) strategy, a technical and management package, based on the earlier work of the International Union Against Tuberculosis and Lung Disease (IUATLD) and international experience with DOTS, which strategy beyond a doubt has played a great role in the initial success of this program, especially in hospitalized patients under the initial intensive phase of 4-drug, anti-TB treatment with Isoniazid, Rifampicin, Pyrazinamide and Ethambutol. This results in rapid clinical well-being and early sputum conversion. This is indeed epidemiologically very important to break the chain of infection. Despite successful implementation of most of the elements of this strategy in several African countries and settings, TB case rates continue to escalate where the prevalence of HIV infection is high. There are also various other reasons which render the patients defaulter. Non-compliance is not only detrimental to the defaulters themselves as seen in this case study, but overall exposes the community to increased risk. Development of acquired resistance is more common in these patients, which makes their management very difficult. Therefore, it is important to anticipate those at risk of being defaulters and make them adhere to anti-TB treatment. It is very rare to trace and know what happened to a defaulter after he or she has dropped out, especially after migrating from one place to another, in the absence of any documentation. The following study is based on the story of a recurrent defaulter, a 64-year-old Saudi male who was admitted on 27 July 2011 to SBAH-City Rehabilitation Hospital & Medical Centre, Riyadh, Saudi Arabia.