BackgroundIn Pakistan, only 59-73% of children 12-23 months of age are fully immunized. This randomized, controlled trial was conducted to assess the impact of a low-literacy immunization promotion educational intervention for mothers living in low-income communities of Karachi on infant immunization completion rates.MethodsThree hundred and sixty-six mother-infant pairs, with infants aged ≤ 6 weeks, were enrolled and randomized into either the intervention or control arm between August - November 2008. The intervention, administered by trained community health workers, consisted of three targeted pictorial messages regarding vaccines. The control group received general health promotion messages based on Pakistan's Lady Health Worker program curriculum. Assessment of DPT/Hepatitis B vaccine completion (3 doses) was conducted 4-months after enrollment. A Poisson regression model was used to estimate effect of the intervention. The multivariable Poisson regression model included maternal education, paternal occupation, ownership of home, cooking fuel used at home, place of residence, the child's immunization status at enrollment, and mother's perception about the impact of immunization on child's health.ResultsBaseline characteristics among the two groups were similar. At 4 month assessment, among 179 mother-infant pairs in the intervention group, 129 (72.1%) had received all 3 doses of DPT/Hepatitis B vaccine, whereas in the control group 92/178 (51.7%) had received all 3 doses. Multivariable analysis revealed a significant improvement of 39% (adjusted RR = 1.39; 95% CI: 1.06-1.81) in DPT-3/Hepatitis B completion rates in the intervention group.ConclusionA simple educational intervention designed for low-literate populations, improved DPT-3/Hepatitis B vaccine completion rates by 39%. These findings have important implications for improving routine immunization rates in Pakistan.

We compared anaerobic lytic (AL) and pediatric aerobic resin-containing (Peds Plus/F) blood culture media for the isolation of Salmonella enterica serotype Typhi or Paratyphi A from children. The yields from AL and Peds Plus/F media were the same with equal volumes of blood, but recovery was faster from AL medium than Peds Plus/F medium (10.7 and 16.4 h, respectively) (P < 0.001).Salmonella enterica serotype Typhi causes an estimated 16 million illnesses per year with 600,000 deaths globally (9). S. enterica serotypes Typhi and Paratyphi A are the most-common causes of community-acquired bacteremia in South Asia; children are affected disproportionately, with high mortality under age 5 years (1, 7, 11). Enteric (typhoid) fever cannot be clinically distinguished from other causes of acute febrile illness in areas of endemicity (9). Accurate microbiological diagnosis currently depends on culture of blood, since culture of bone marrow is rarely done now and most children are treated as outpatients. The Bactec Peds Plus/F (PP; BD DiagnosticsDiagnostic Systems, Sparks, MD) bottle, an aerobic blood culture medium with resins, is a commercial pediatric bottle commonly used worldwide. The standard recommendation for culturing blood in a single PP bottle is based on its demonstrated superior recovery of pathogens such as Streptococcus pneumoniae and the infrequency of anaerobic pathogens in children in North America (14).We hypothesized that the optimal pediatric bottle for North America might not be best for South Asia and that an anaerobic lytic bottle might theoretically be better for the recovery of S. enterica serotypes Typhi and Paratyphi A in areas of the world where Salmonella organisms are the most-common pathogens recovered from blood. Although Salmonella bacteria are facultative anaerobes, isolates requiring strict anaerobic conditions for growth have been reported (6). Furthermore, the historic superiority of culture of bone marrow (sensitivity, 80% to 95%) over culture of blood (sensitivity, 60% to 80%) has been attributed to recovery of intracellular bacilli from mononuclear phagocytes (5, 9, 12). Recent studies from Vietnam suggest that ϳ66% of bacteria in blood are also harbored within phagocytes, and thus, lysis of circulating macrophages in blood might improve the yield of blood cultures (9). Because inadequate blood sampling is frequent in pediatrics and could confound the comparison of media, we undertook a volumecontrolled evaluation of PP versus Bactec lytic/10 anaerobic/F (AL) (BD Diagnostics-Diagnostic Systems) media to assess the yield and time to detection of Salmonella from the blood of children. For our study site, we chose Karachi, Pakistan, since S. enterica serotypes Typhi and Paratyphi A are the mostcommon causes of pediatric bacteremia in Pakistan (2) and the presence of a state-of-the-art clinical microbiology laboratory at Aga Khan University Hospital enabled the comparison of these media. The study was approved by ethical review boards at both the Children's Hospital Boston and Aga Kha...