In light of the influenza A (H1N1) pandemic, the Strategic Advisory Group of Experts on Immunization of the World Health Organization requested that the acute flaccid paralysis surveillance system of Latin American and the Caribbean be used to establish Guillain-Barré syndrome incidence rates. An analysis was conducted of 10,486 acute flaccid paralysis cases diagnosed as Guillain-Barré syndrome from 2000 through 2008 in children aged <15 years in Latin American and the Caribbean countries and territories. The average incidence was 0.82 cases per 100,000 children aged <15 years (range, 0.72-0.90 cases per 100,000 children), with significant differences between northern and southern countries (1.08 vs 0.57 cases per 100,000 children). The acute flaccid paralysis surveillance system represents a useful means of monitoring Guillain-Barré syndrome during the pandemic.
HighlightsGlobal and regional action plans call for improved immunization data quality.Mexico and Peru created information systems to improve data quality.Mexico’s immunization registry failed, but the country is reworking its system.Peru’s system has improved data quality, while addressing social priorities.Funding and capacity-building affect sustainability of immunization registries.
Background. Despite the success of the Dominican Republic's National Immunization Program, homogenous vaccine coverage has not been achieved. In October 2012, the country implemented a study on missed opportunities for vaccination (MOVs) in children aged <5 years. Methods. A cross-sectional study of 102 healthcare facilities was implemented in 30 high-risk municipalities. Overall, 1500 parents and guardians of children aged <5 years were interviewed. A MOV is defined as when a person who is eligible for vaccination and with no contraindications visits a health facility and does not receive a required vaccine. We evaluated the causes of MOVs and identified risk factors associated with MOVs in the Dominican Republic. Results. Of the 514 children with available and reliable vaccination histories, 293 (57.0%) were undervaccinated after contact with a health provider. Undervaccinated children had 836 opportunities to receive a needed vaccine. Of these, 358 (42.8%) qualified as MOVs, with at least one MOV observed in 225 children (43.7%). Factors associated with MOVs included urban geographic area (OR = 1.80; p = 0.02), age 1–4 years (OR = 3.63; p ≤ 0.0001), and the purpose of the health visit being a sick visit (OR = 1.65; p = 0.02). Conclusions. MOVs were associated primarily with health workers failing to request and review patients' immunization cards.
In Latin America and the Caribbean, pneumococcus has been estimated to cause 12,000-28,000 deaths, 182,000 hospitalizations, and 1.4 million clinic visits annually. Countries in the Americas have been among the first developing nations to introduce pneumococcal conjugate vaccines into their Expanded Programs on Immunization, with 34 countries and territories having introduced these vaccines as of September 2015. Lessons learned for successful vaccine introduction include the importance of coordination between political and technical decision makers, adjustments to the cold chain prior to vaccine introduction, and the need for detailed plans addressing the financial and technical sustainability of introduction. Though many questions on the Pneumococcal Conjugate Vaccine remain unanswered, the experience of the Americas suggests that the vaccines can be introduced quickly and effectively.
BackgroundImmunization coverage levels in Guatemala have increased over the last two decades, but national targets of ≥95% have yet to be reached. To determine factors related to undervaccination, Guatemala’s National Immunization Program conducted a user-satisfaction survey of parents and guardians of children aged 0–5 years. Variables evaluated included parental immunization attitudes, preferences, and practices; the impact of immunization campaigns and marketing strategies; and factors inhibiting immunization.MethodsBased on administrative coverage levels and socio-demographic indicators in Guatemala’s 22 geographical departments, five were designated as low-coverage and five as high-coverage areas. Overall, 1194 parents and guardians of children aged 0–5 years were interviewed in these 10 departments. We compared indicators between low- and high-coverage areas and identified risk factors associated with undervaccination.ResultsOf the 1593 children studied, 29 (1.8%) were determined to be unvaccinated, 458 (28.8%) undervaccinated, and 1106 (69.4%) fully vaccinated. In low-coverage areas, children of less educated (no education: RR = 1.49, p = 0.01; primary or less: 1.39, p = 0.009), older (aged >39 years: RR =1.31, p = 0.05), and single (RR = 1.32, p = 0.03) parents were more likely to have incomplete vaccination schedules. Similarly, factors associated with undervaccination in high-coverage areas included the caregiver’s lack of education (none: RR = 1.72, p = 0.0007; primary or less: RR = 1.30, p = 0.05) and single marital status (RR = 1.36, p = 0.03), as well as the child’s birth order (second: RR = 1.68, p = 0.003). Although users generally approved of immunization services, problems in service quality were identified. According to participants, topics such as the risk of adverse events (47.4%) and next vaccination appointments (32.3%) were inconsistently communicated to parents. Additionally, 179 (15.0%) participants reported the inability to vaccinate their child on at least one occasion. Compared to high-coverage areas, participants in low-coverage areas reported poorer service, longer wait times, and greater distances to health centers. In high-coverage areas, participants reported less knowledge about the availability of services.ConclusionsGenerally, immunization barriers in Guatemala are related to problems in accessing and attaining high-quality immunization services rather than to a population that does not adequately value vaccination. We provide recommendations to aid the country in maintaining its achievements and addressing new challenges.
BackgroundThe Expanded Program on Immunization (EPI) in Colombia has made great advances since its inception in 1979; however, by 2010 vaccination coverage rates had been declining. In 2010, the EPI commissioned a nationwide study on practices on immunization, attitudes and knowledge, perceived service quality, and barriers to childhood immunization in order to tailor EPI communication strategies.MethodsColombia’s 32 geographical departments were divided into 10 regions. Interviewers from an independent polling company administered a survey to 4802 parents and guardians of children aged <5 years in these regions. To better assess barriers to vaccination, the study was designed to have 70% of participants who had children with incomplete vaccination schedules. Explanatory factorial, principal component, and cluster analyses were performed to place participants into a group (segment) representing the primary category of reasons respondents offered for not vaccinating their children. Types of barriers were then compared to other variables, such as service quality, communication preferences, and parental attitudes on vaccination.ResultsAlthough all respondents indicated that vaccines have health benefits, and 4738 (98.7%) possessed vaccination cards for their children, attitudes and knowledge were not always favorable to immunization. Six groups of immunization barriers were identified: 1) factors related to caregivers (24.4%), 2) vaccinators (19.7%), 3) health centers (18.0%), 4) the health system (13.4%), 5) concerns about adverse events (13.1%), and 6) cultural and religious beliefs (11.4%); groups 1, 5 and 6 together represented almost half (48.9%) of users, indicating problems related to the demand for vaccines as the primary barriers to immunization. Differences in demographics, communication preferences, and reported service quality were found among participants in the six groups and among participants in the 10 regions. Additionally, differences between how participants reported receiving information on vaccination and how they believed such information should be communicated were observed.ConclusionsBetter understanding immunization barriers and the users of the EPI can help tailor communication strategies to increase demand for immunization services. Results of the study have been used by Colombia’s EPI to inform the design of new communication strategies.
Despite increased awareness of Choosing Wisely (CW) ® recommendations to reduce low-value care, 1 there is limited published data about strategies to implement these guidelines or evidence that they have influenced ordering patterns or reduced healthcare spending. [2][3][4][5][6] Implementation science seeks to accelerate the translation of evidence-based interventions into clinical practice and the deimplementation of low-value care. [7][8][9] Based on established principles of implementation science, we used a prospective, nonrandomized study design to assess a CW intervention to reduce chest X-ray (CXR) ordering in adult intensive care units (ICUs). 10 In ICUs, CXR ordering strategies may be routine (daily) or on-demand (with clinical indication). The former strategy's principal advantage is the potential to detect life-threatening situations that may otherwise escape diagnosis. 11 Disadvantages include cost, radiation exposure, patient inconvenience, false-positive workups, and low diagnostic and therapeutic value. 12,13 On-demand strategies may safely reduce CXR ordering by 32% to 45%. [11][12][13][14][15][16][17] Based on this evidence, the Critical Care Societies Collaborative and the American College of Radiology have recommended on-demand CXR ordering. 18,19 Here, we describe the effectiveness of an intervention to reduce CXR ordering in two ICUs while evaluating the deimplementation strategies using a validated framework. METHODS Setting and DesignVanderbilt University Medical Center (VUMC) is an academic referral center in Nashville, Tennessee. The cardiovascular ICU (CVICU) has 27 beds and the medical ICU (MICU) has 34 beds. Acute care nurse practitioners (ACNPs) and two critical care physicians staff the CVICU; cardiology fellows, anesthesia critical
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