Disparity in childhood immunizations

Improved vaccine coverage for First Nations children receiving first dose on-reserve: a retrospective cohort study in western Canada

INTRODUCTION

Fragmentation in immunisation reporting systems pose challenges in measuring vaccine coverage for First Nations children in Canada. Some Nations have entered into data-sharing agreements with the province of Alberta's health ministry, enabling novel opportunities to calculate coverage.

METHODS

Partnering with a First Nations community in Alberta, this retrospective cohort study calculated routine childhood vaccine coverage. Administrative data for vaccines delivered within and outside the community were linked to calculate partial and complete immunisation coverage in 2013-2019 at ages 2 and 7 years for children living in the community. We also compared vaccine coverage each year for (a) children who were and were not continuous community residents and (b) children who received or not their first vaccine at the on-reserve community health centre. We also calculated the mean complete coverage across all study years with 95% CIs.

RESULTS

For most vaccines, coverage was higher (p<0.05) at ages 2 and 7 years for children that received their first vaccine at the First Nations health centre, compared with those who received their first dose elsewhere. For example, for pneumococcal vaccine, the mean level of complete coverage in 2-year-olds was 55.7% (52.5%-58.8%) for those who received their first vaccine in the community, compared with 33.3% (29.4%-37.3%) for those who did not; it was also higher at 7 years (75.6%, 72.7%-78.5%, compared with 55.5%, 49.7%-61.3%).

CONCLUSION

Initiating the vaccine series at the on-reserve community health centre had a positive impact on coverage. The ability to measure accurate coverage through data-sharing agreements and vaccine record linkage will support First Nations communities in identifying individual and community immunity. The findings also support the transfer of health funding and service delivery to First Nations to improve childhood immunisation uptake.

Factors influencing human papillomavirus school-based immunization in Alberta: A mixed-methods study protocol

More than 1,300 Canadians are diagnosed with cervical cancer annually, which is nearly preventable through human papillomavirus (HPV) immunization. Across Canada, coverage rates remain below the 90% target set out by the Action Plan for the Elimination of Cervical Cancer in Canada (2020-2030). To support this Plan, the Canadian Partnership Against Cancer has commissioned the Urban Public Health Network (UPHN) to coordinate a quality improvement project with Canada's school-based HPV immunization programs. In Alberta, the UPHN partnered with Alberta Health Services (AHS) for this work. This study has one overarching research question: what are parent/guardian and program stakeholder perceived barriers, enablers and opportunities to immunization for youth as part of the school-based HPV immunization program in Alberta? This study uses a mixed-methods sequential explanatory design. A survey will be emailed to a sample of Albertans with children aged 11-17 years. Questions will be based on a Conceptual Framework of Access to Health Care. Subsequent qualitative work will explore the survey's findings. Parents/guardians identifying as vaccine hesitant in the survey will be invited to participate in virtual, semi-structured, in-depth interviews. Stakeholders of the school-based immunization program will be purposively sampled from AHS' five health zones for virtual focus groups. Quantitative data will be analyzed using SAS Studio 3.6 to carry out descriptive statistics and, using logistic regression, investigate if Framework constructs are associated with parents'/guardians' decision to immunize their children. Qualitative data will be analyzed using NVivo 12 to conduct template thematic analysis guided by the Framework. Study results will provide insights for Alberta's public health practitioners to make evidence-informed decisions when tailoring the school-based HPV immunization program to increase uptake in vaccine hesitant populations. Findings will contribute to the national study, which will culminate in recommendations to increase HPV immunization uptake nationally and progress towards the 90% coverage target.

Trends, barriers and enablers to measles immunisation coverage in Saskatchewan, Canada: A mixed methods study

Many social, cultural, and systemic challenges affect the uptake of measles immunisation services. Prior studies have looked at the caregivers' perspectives, but little is known about the perspectives of the health care providers on the barriers of measles immunisation services in Canada. This study examined measles immunisation coverage trends across the regional health authorities in Saskatchewan and explored the barriers and enablers to measles immunisation coverage from providers' perspectives. The study adopted an explanatory sequential mixed method. We utilized the entire population of 16,582 children under two years of age available in the Saskatchewan Immunisation Management System (SIMS) registry for 2002 and 2013 in aggregate format and interviewed 18 key informants in pre-determined two-stages in 2016 and 2017. The quantitative analysis was done with Joinpoint regression modelling, while the qualitative interview data was analyzed using hybrid inductive and deductive thematic approaches. There was a 16.89%-point increase in measles immunisation coverage in the province from 56.32% to 73.21% between 2002 and 2013. There was also a persistently higher coverage among the affluent (66.95% - 82.37%) than the most deprived individuals (45.79% - 62.60%) in the study period. The annual rate of coverage change was marginally higher among the most deprived (16.81%; and average annual percentage change (AAPC) 2.0, 95% CI 1.7-2.2) than among the affluent group (15.42% and AAPC 3.0; 95% CI 2.0-4.0). While access-related issues, caregivers' fears, hesitancy, anti-vaccination challenges, and resource limitations were barriers to immunisation, improving community engagement, service delivery flexibility, targeted social responses and increasing media role were found useful to address the uptake of measles and other vaccine-preventable diseases immunisation. There is low coverage and inequity in measles immunisation uptake in Saskatchewan from social and institutional barriers. Even though there is evidence of disparity reduction among the different groups, the barriers to increasing measles immunisation coverage have implications for the health of the socio-economically deprived groups, the healthcare system and other vaccination programs. There is a need to improve policy framework for community engagement, targeted programs, and public health discourse.

Reasons and suggestions for improving low immunization uptake among children living in low socioeconomic status communities in Northern Alberta, Canada - A qualitative study

OBJECTIVE

Under-immunization increases the risk of acquiring vaccine-preventable diseases in children and the community. The targeted coverage rate for routine childhood immunization in Alberta, especially in disadvantaged communities in rural and remote geographic areas, has not been achieved for many years. This study was conducted to identify reasons for under-immunization in children in low socioeconomic status (SES) communities and propose suggestions to address issues/concerns identified by low SES parents for improving immunization coverage in their communities.

METHODS

Fourteen semi-structured phone interviews of low SES parents with under-immunized children living in rural and remote geographic areas in Northern Alberta were conducted. Transcripts were analyzed to identify relevant themes.

RESULTS

Busy lifestyles of many parents prevented them from taking their children to clinics for immunization, which were exacerbated by long distances to clinics, transportation issues, operating hours of clinics, and lack of reminders. Many disadvantaged parents also exhibited varying levels of vaccine hesitancy due to safety concerns, especially about newer vaccines, thereby causing some parents to delay immunizing their child intentionally.

CONCLUSION

Implementing procedures to alleviate access issues, such as offering extended operating hours, opening drop-in clinics/satellite clinics in distant areas, nurse visits to their homes, updating contact information of parents, frequent reminder options and addressing safety and effectiveness concerns about vaccines in plain language using evidence-based communication strategies can promote timely immunization among children of low SES parents.

An equity-based assessment of immunization-related responses in urban Alberta during the 2014 measles outbreak: a comparative analysis between Calgary and Edmonton

OBJECTIVES

This study investigates measles, mumps, and rubella (MMR) immunization rates during the measles outbreak in Calgary and Edmonton of 2014 stratified by four area-level socio-demographic indicators. This study also leverages this epidemiological data to assess the equity aspect of emergency measures instituted regarding immunization in those two cities.

METHODS

A mixed-methods comparative case study analysis methodology was employed to assess the neighbourhood-level immunization statuses before (2013), during (2014), and after (2015) an active measles outbreak in Calgary and Edmonton, Alberta, Canada. The epidemiological one-dose by age-2 MMR coverage data were stratified using four socio-demographic indicators: median household income, %-homeownership, %-Aboriginal population, and %-immigrant population. Document and content analysis was utilized to investigate the outbreak mitigation strategies deployed in each city.

RESULTS

The measles outbreak of 2013/2014 involved the entirety of Alberta and led to both provincial and city-specific interventions in which Calgary deployed three mass immunization clinics in 2014, where Edmonton did not. The Calgary coverage data showed an increase in coverage inequalities across all indicators and the Edmonton data showed mixed results in terms of equity gains/losses. Calgary's additive intervention of three mass immunization clinics in 2014 appears to have contributed to both the higher gross immunization rates in Calgary (90.77%) and an inequitable increase in coverage rates as compared with Edmonton (88.96%), in most cases.

CONCLUSION

Public health policy-makers must be cognizant that large-scale public health efforts must be optimized for accessibility across all socio-economic levels to ensure public and population health gains are realized equitably.

HPV vaccine: uptake and understanding among global Indigenous communities - a qualitative systematic review

BACKGROUND

Indigenous populations have a high prevalence of Human Papillomavirus (HPV) infection and a high incidence of HPV associated cancers, such as cervical and oropharyngeal cancer. There is an effective HPV vaccination program in almost all developed countries to prevent the incidence of cervical cancer, but reports suggest that the uptake of these vaccinations by Indigenous populations is low. The objective of this qualitative systematic review was to explore the knowledge and beliefs of global Indigenous populations regarding HPV vaccines. This review was performed to identify the barriers faced by Indigenous peoples and to provide evidence for more effective and acceptable execution of vaccination policies for Indigenous peoples.

METHODS

Two investigators independently searched MEDLINE, PubMed, SCOPUS, and Web of Science databases using a pre-specified search strategy to identify qualitative studies on narratives of Indigenous peoples regarding HPV vaccine awareness, knowledge and experiences across all geographic and income-level settings.

RESULTS

After performing the literature search and quality appraisals 5 papers were included in the final review. Three core synthesised findings were identified: reasons for acceptance or hesitancy, and areas for improvement. Lack of correct knowledge and mistrust in the healthcare system were important categories observed in all papers included in the review. Other categories within the conceptual model included prioritising disease prevention, health professional guidance, family support and supportive community environment.

CONCLUSION

Qualitative systematic reviews are an excellent means of exploring the gaps in current healthcare practices. Indigenous healthcare research should be grounded in community experiences and feedback. This review provides insights into HPV vaccination understanding and acceptance amongst Indigenous populations, from which recommendations for increasing resonance of vaccination strategies with Indigenous communities can be formed.

Association between participation in the Families First Home Visiting programme and First Nations families' public health outcomes in Manitoba, Canada: a retrospective cohort study using linked administrative data

OBJECTIVE

To determine whether the Families First Home Visiting (FFHV) programme, which provides home visiting services to families across Manitoba, is associated with improved public health outcomes among First Nations families facing multiple parenting challenges.

DESIGN

Retrospective cohort study using population-based administrative data.

SETTING

Manitoba, Canada.

PARTICIPANTS

First Nations children born in Manitoba in 2003-2009 (n=4010) and their parents enrolled in FFHV compared with non-enrolled families with a similar risk profile.

INTERVENTION

FFHV supports public health in Manitoba by providing home visiting services to First Nations and non-First Nations families with preschool children and connecting them with resources in their communities.

OUTCOMES

Predicted probability (PP) and relative risk (RR) of childhood vaccination, parental involvement in community support programmes and children's development at school entry.

RESULTS

FFHV participation was associated with higher rates of complete childhood vaccination at age 1 (PP: FFHV 0.715, no FFHV 0.661, RR 1.08, 95% CI 1.03 to 1.14) and age 2 (PP: FFHV 0.465, no FFHV 0.401, RR 1.16, 95% CI 1.08 to 1.25), and with parental involvement in community support groups (PP: FFHV 0.149, no FFHV 0.097, RR 1.54, 95% CI 1.27 to 1.86). However, there was no difference between FFHV participants and non-participants in rates of children being vulnerable in at least one developmental domain at age 5 (PP: FFHV 0.551, no FFHV 0.557, RR 1.00, 95% CI 0.91 to 1.11).

CONCLUSIONS

FFHV supports First Nations families in Manitoba by promoting childhood vaccination and connecting families to parenting resources in their communities, thus playing an important role in fulfilling the mandate of public health practice.

Barriers, supports, and effective interventions for uptake of human papillomavirus- and other vaccines within global and Canadian Indigenous peoples: a systematic review protocol

BACKGROUND

Despite the existence of human papilloma virus (HPV) vaccines with demonstrated safety and effectiveness and funded HPV vaccination programs, coverage rates are persistently lower and cervical cancer burden higher among Canadian Indigenous peoples. Barriers and supports to HPV vaccination in Indigenous peoples have not been systematically documented, nor have interventions to increase uptake in this population. This protocol aims to appraise the literature in Canadian and global Indigenous peoples, relating to documented barriers and supports to vaccination and interventions to increase acceptability/uptake or reduce hesitancy of vaccination. Although HPV vaccination is the primary focus, we anticipate only a small number of relevant studies to emerge from the search and will, therefore, employ a broad search strategy to capture literature related to both HPV vaccination and vaccination in general in global Indigenous peoples.

METHODS

Eligible studies will include global Indigenous peoples and discuss barriers or supports and/or interventions to improve uptake or to reduce hesitancy, for the HPV vaccine and/or other vaccines. Primary outcomes are documented barriers or supports or interventions. All study designs meeting inclusion criteria will be considered, without restricting by language, location, or data type. We will use an a priori search strategy, comprised of key words and controlled vocabulary terms, developed in consultation with an academic librarian, and reviewed by a second academic librarian using the PRESS checklist. We will search several electronic databases from date of inception, without restrictions. A pre-defined group of global Indigenous websites will be reviewed for relevant gray literature. Bibliographic searches will be conducted for all included studies to identify relevant reviews. Data analysis will include an inductive, qualitative, thematic synthesis and a quantitative analysis of measured barriers and supports, as well as a descriptive synthesis and quantitative summary of measures for interventions.

DISCUSSION

To our knowledge, this study will contribute the first systematic review of documented barriers, supports, and interventions for vaccination in general and for HPV vaccination. The results of this study are expected to inform future research, policies, programs, and community-driven initiatives to enhance acceptability and uptake of HPV vaccination among Indigenous peoples.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO Registration Number: CRD42017048844.

Families First Home Visiting programme reduces population-level child health and social inequities

BACKGROUND

Home visiting has been shown to reduce child maltreatment and improve child health outcomes. In this observational study, we explored whether Families First, a home visiting programme in Manitoba, Canada, decreased population-level inequities in children being taken into care of child welfare and receiving complete childhood immunisations.

METHODS

De-identified administrative health and social services data for children born 2003-2009 in Manitoba were linked to home visiting programme data. Programme eligibility was determined by screening for family risk factors. We compared probabilities of being taken into care and receiving immunisations among programme children (n=4575), eligible children who did not receive the programme (n=5186) and the general child population (n=87 897) and tested inequities using differences of risk differences (DRDs) and ratios of risk ratios (RRRs).

RESULTS

Programme children were less likely to be taken into care (probability (95% CI) at age 1, programme 7.5 (7.0 to 8.0) vs non-programme 10.0 (10.0 to 10.1)) and more likely to receive complete immunisations (probability at age 1, programme 77.3 (76.5 to 78.0) vs non-programme 73.2 (72.1 to 74.3)). Inequities between programme children and the general population were reduced for both outcomes (being taken into care at age 1, DRD -2.5 (-3.7 to 1.2) and RRR 0.8 (0.7 to 0.9); complete immunisation at age 1, DRD 4.1 (2.2 to 6.0) and RRR 1.1 (1.0 to 1.1)); these inequities were also significantly reduced at age 2.

CONCLUSION

Home visiting programmes should be recognised as effective strategies for improving child outcomes and reducing population-level health and social inequities.

Visually enhanced education and immunization perceptions in low-income parents

OBJECTIVE

Despite immunizations being an effective health promotion intervention, about 28% of children are not up-to-date on the combined seven-vaccine series by 35 months of age in the United States. Identifying innovative techniques to increase immunization literacy is crucial to the health and well-being of children.

DESIGN AND SAMPLE

Based on the theory of multimedia learning, this study examined whether the use of visually enhanced education (VEE) positively impacted parental perception of immunization effectiveness, perceived knowledge of disease, comfort with immunization decision making, and satisfaction with the provider. Forty parents of infants 4-14 days old that could read English.

INTERVENTION

Parents completed a questionnaire with 12 items in four categories during the initial visit (4-14 days old) before VEE and at the second visit (17-37 days later) after the second VEE session had been completed.

RESULTS

A paired sample t test revealed a significant increase in two of the four categories (i.e., perceived knowledge of the disease [t(37) = 8.73, p = .000] and satisfaction with the provider [t(37) = 2.68, p = .011]. Cohen's effect size value suggested high practical significance in one of the four categories (i.e., perceived knowledge of disease d = 1.31, d = 1.42, d = 1.18, d = 1.05, d = 1.12). Cronbach's alpha for the 12 items was 0.852.

CONCLUSIONS

VEE may be an innovative technique for improving parental immunization health literacy and increasing parent-professional communication about immunizations.

Socioeconomic differences in childhood vaccination in developed countries: a systematic review of quantitative studies

INTRODUCTION

The reasons for vaccine hesitancy and its relation to individual socioeconomic status (SES) must be better understood. Areas covered: This review focused on developed countries with programs addressing major financial barriers to vaccination access. We systematically reviewed differences by SES in uptake of publicly funded childhood vaccines and in cognitive determinants (beliefs, attitudes) of parental decisions about vaccinating their children. Using the PRISMA statement to guide this review, we searched three electronic databases from January 2000 through April 2016. We retained 43 articles; 34 analyzed SES differences in childhood vaccine uptake, 7 examined differences in its cognitive determinants, and 2 both outcomes. Expert commentary: Results suggest that barriers to vaccination access persist among low-SES children in several settings. Vaccination programs could be improved to provide all mandatory and recommended vaccines 100% free of charge, in both public organizations and private practices, and to reimburse vaccine administration. Multicomponent interventions adapted to the context could also be effective in reducing these inequalities. For specific vaccines (notably for measles, mumps, and rubella), in UK and Germany, uptake was lowest among the most affluent. Interventions carefully tailored to respond to specific concerns of vaccine-hesitant parents, without reinforcing hesitancy, are needed.

Connecting remote populations to public health: the case for a digital immunisation information system in Nunavut

Despite the best efforts of local healthcare workers and health officials, Nunavut, a large geographical region in Northern Canada, has struggled with outbreaks of vaccine-preventable diseases (VPD). We contend that the implementation of an immunisation information system (IIS) could strengthen prevention and response efforts to this and future outbreaks of vaccine-preventable diseases. Developing an IIS in Nunavut that builds on the existing CANImmunize infrastructure would reduce the cost and complexity of developing a new IIS, and allow Nunavut to benefit from the ongoing efforts to secure data on the CANImmunize platform. Such a system would enable the identification of individuals and subpopulations at highest risk of infection based on vaccine series completion and permit the exploration of the underlying causes of outbreaks in the territory through consideration of demographic and temporal factors. Confirmed high rates of vaccination in the context of an outbreak would indicate potential issues with vaccine efficacy while low rates of vaccination would suggest that efforts should be devoted to increasing vaccine coverage. This approach could also lay the foundation for infrastructure expansion to other remote and/or Indigenous communities where geographical and accessibility issues complicate health care utilisation and monitoring, both in Canada and internationally.

Uptake of pneumococcal vaccines in the Nordic region of Nunavik, province of Quebec, Canada

OBJECTIVES

Pneumococcal infections constitute an important public health problem in Nordic regions of Canada. Nordic populations are not included in national and provincial immunization surveys and there is no centralized immunization registry in these regions. The objective of this study was to estimate pneumococcal vaccination coverage and delays in immunization of children in Nunavik, Quebec.

METHODS

Immunization records of children born in 1994-2005 were collected in all villages. Children were classified into three groups: born in the period January 1, 1994 to April 30, 1997 and targeted by the 2002 mass campaign with the 23-valent polysaccharide vaccine (PPSV23); born in the period May 1, 1997 to March 31, 2002 and targeted by the 7-valent conjugate vaccine (PCV7) catch-up campaign; born in the period April 1, 2002 to December 31, 2005 and targeted by the PCV7 routine infant program.

RESULTS

In the first group (n=896), 86.8% (95% CI: 84.4%-89.0%) were vaccinated with PPSV23. In the second group (n=1,252), 84.3% (95% CI: 82.1%-86.2%) received ≥1 PCV7 dose. In the third group, 90.4% (95% CI: 88.5%-92.1%) received 4 PCV7 doses. Delays >4 weeks in vaccine administration were observed for 26.3% of doses. There were substantial variations between villages for all indicators.

CONCLUSIONS

In the challenging setting of a Nordic and remote region, uptake rates of pneumococcal vaccines in Nunavik were found to be similar to those measured in population surveys in Quebec.

How parents make decisions about their children's vaccinations

BACKGROUND

Continued parental acceptance of childhood vaccination is essential for the maintenance of herd immunity and disease prevention. As such, understanding parents' decision-making in relation to their children's vaccinations is vitally important.

OBJECTIVE

This qualitative study sought to develop an understanding of the general process parents go through when making decisions about their children's vaccinations.

METHODS

Interviews were conducted with U.S.-born parents living in King County, Washington who had children ≤18 months of age. These interviews were recorded and transcribed verbatim.

RESULTS

Through the application of grounded theory, a general decision-making process was identified. Stages in this process included: awareness, assessing and choosing, followed by either stasis or ongoing assessment. The greatest variation occurred during the assessing stage, which involved parents examining vaccination-related issues to make subsequent decisions. This research suggests that three general assessment groups exist: acceptors, who rely primarily on general social norms to make their vaccination decisions; reliers, who rely primarily on other people for information and advice; and searchers, who seek for information on their own, primarily from published sources.

CONCLUSIONS

These results imply that one-size-fits-all approaches to vaccination interventions are inappropriate. Instead, this research suggests that interventions must be targeted to parents based on how they assess vaccination.

The effectiveness of telephone reminders and home visits to improve measles, mumps and rubella immunization coverage rates in children

INTRODUCTION

In the Saskatoon Health Region (Saskatchewan), only 67.4% of children overall are fully immunized for measles, mumps and rubella (MMR) at 24 months of age, with only 43.7% of low-income children fully immunized.

METHODS

Parents of children who were behind in MMR immunizations were contacted to determine knowledge about, beliefs toward and barriers to immunization. The effectiveness of a telephone reminder system in improving immunization rates in a health region compared with a control health region was determined. Finally, the effectiveness of telephone reminders versus telephone reminders combined with home visits in improving child immunization coverage rates in low-income neighbourhoods was compared.

RESULTS

The survey was completed by 629 parents (69% response rate). Of those, 81.8% were not aware that their child was behind in immunizations. In the Saskatoon Health Region, the MMR immunization coverage increased from 67.4% to 74.0% in the first year of intervention (rate ratio = 1.10; 95% CI 1.08 to 1.12). All four neighbourhood groupings (three urban by income and one rural) had relative increases ranging from 9% to 11%. The control health region observed an immunization coverage increase from 66.5% to 69.2% in the first year (rate ratio = 1.04; 95% CI 1.01 to 1.07). The three low-income neighbourhoods with only telephone reminders had an immunization coverage rate of 48.7% (95% CI 39.5% to 57.8%). The three low-income neighbourhoods that received a telephone reminder and home visit had an immunization coverage rate of 60.5% (95% CI 52.5% to 68.6%).

CONCLUSION

Telephone reminder systems have some benefit in increasing child immunization coverage rates.

Social determinants of health and the future well-being of Aboriginal children in Canada

Aboriginal children's well-being is vital to the health and success of our future nations. Addressing persistent and current Aboriginal health inequities requires considering both the contexts in which disparities exist and innovative and culturally appropriate means of rectifying those inequities. The present article contextualizes Aboriginal children's health disparities, considers 'determinants' of health as opposed to biomedical explanations of ill health and concludes with ways to intervene in health inequities. Aboriginal children experience a greater burden of ill health compared with other children in Canada, and these health inequities have persisted for too long. A change that will impact individuals, communities and nations, a change that will last beyond seven generations, is required. Applying a social determinants of health framework to health inequities experienced by Aboriginal children can create that change.

Coverage for the entire population: tackling immunization rates and disparities in Saskatoon Health Region

OBJECTIVE

Our objective was to determine the effectiveness of an intervention, the Immunization Reminders Project, in terms of a) improving vaccination coverage rates for measles, mumps and rubella (MMR) among 2-year-olds and b) ameliorating geographical disparities in early childhood immunization coverage.

TARGET POPULATION

All 14-month-old and 20-month-old children in Saskatoon Health Region who were overdue for their immunizations.

SETTING

Saskatoon Health Region (SHR).

INTERVENTION

The intervention involved calling the parents/caregivers of the children in the target population with a reminder about immunizations. After five telephone calls and if the parent/caregiver could not be reached, a letter was mailed to the last known address. If there was no response to the letter, a reminder home visit was attempted for families residing in the low-income neighbourhoods in Saskatoon. Since January 2009, all reminders for families not residing in the low-income neighbourhoods in Saskatoon are made through mailed letters.

OUTCOMES

After the introduction of the Immunization Reminders Project, coverage rates among 2-year-olds for MMR increased significantly overall and in most geographical areas examined. Disparities between geographical subgroups appeared to be declining, but not significantly.

CONCLUSION

A universal approach to early childhood immunization can likely contribute to increases in coverage rates, but there is still room for improvement in SHR. These findings have prompted additional practice and policy changes.

Tetanus in developing countries: a case series and review

PURPOSE

Few anesthesiologists have expertise in the diagnosis and treatment of tetanus, a disease that remains prevalent in developing countries. We report on a series of four cases of tetanus cases recently encountered in Rwanda. We review the clinical epidemiology, pathophysiology, diagnosis and the treatment of tetanus, and provide implications for anesthesiologists and critical care physicians.

CLINICAL FEATURES

We report four cases, two involving adults who were inadequately vaccinated and experienced injuries, and two involving neonates, both of whom underwent umbilical cord transection using unsterilized equipment. All patients required tracheal intubation, and were mechanically ventilated when equipment was available. One adult and one neonate succumbed to the disease. These cases highlight the difficulties of diagnosis and management of complicated diseases in the resource-challenged health care setting of developing countries.

CONCLUSIONS

The differential diagnosis of tetanus may be confusing, and survival depends on the rapidity of treatment with antitoxin, as well as adequate supportive care. High doses of sedatives and muscle relaxants, as well as prolonged mechanical ventilation, are usually necessary. Mortality remains high, usually resulting from late respiratory failure and cardiovascular collapse, associated with autonomic instability. Anesthesiologists and critical care physicians have an important role to play in the management of these patients. Increased involvement in humanitarian health organizations, immigration from developing countries, and emergence of high risk groups in developed countries will likely result in more exposure of anesthesiologists to the complexities of this disease.