Overview of the pediatric healthcare system in Romania

Cost-effectiveness analysis of implementing 20-valent pneumococcal conjugate vaccine into the Romanian pediatric national immunization program

INTRODUCTION

Despite the inclusion of pneumococcal conjugate vaccines (PCV) in the pediatric national immunization program (NIP) since 2017, Romania continues to face a substantial clinical, economic, and societal burden of pneumococcal disease. Higher-valent vaccines, such as 20-valent PCV (PCV20), offer broader serotype coverage versus the current standard of care (13-valent PCV; PCV13) with the potential to reduce disease burden. To test this, we conducted a cost-effectiveness analysis of switching from PCV13 or a potential future comparator (15-valent PCV; PCV15), both under a 2 + 1 schedule, to PCV20 under a 3 + 1 schedule in the Romanian pediatric NIP.

METHODS

A population-based, multi-cohort Markov model with a target population of children aged <2 years was utilized to estimate the cost and health impact of PCV20 versus lower-valent comparators over 10 years. The model adopted a Romanian societal perspective, encompassing both direct and indirect costs, with an annual cycle. Sensitivity and scenario analyses were conducted to assess the robustness of the model and its assumptions.

RESULTS

In the base-case analysis, PCV20 demonstrated dominance versus PCV13 and PCV15 (i.e., was more effective and less costly), with total predicted cost-savings of 79,123,267 and 206,623,098 Romanian Leu, respectively, plus reduction in pneumococcal disease cases by 246,245 and 223,914, respectively. The majority of sensitivity and scenario analyses of both pairwise comparisons were aligned with the base case.

CONCLUSION

The results of this analysis indicate that PCV20 implementation into the Romanian pediatric NIP would greatly reduce pneumococcal disease burden and would be a cost-effective approach versus PCV13 or PCV15 from a societal perspective over 10 years.

Transition Readiness in Pediatric Chronic Digestive Diseases: A Regional Perspective from North-Eastern Romania

Background: The transition from the pediatric to the adult healthcare system is a challenging process involving adolescents, parents, and pediatric and adult specialists. For a successful approach for an organized transition program, we must assess the level of training of adolescents facing transition. Methods: We applied a clinic-based questionnaire measuring perceived self-management skills, adherence to health-related tasks, medication knowledge, and social adjustment to pediatric patients with chronic digestive diseases from North-East Romanian medical units, including a tertiary center and private practice offices. Results: There were 124 participants; 73.38% from rural areas, 26.62% from urban areas; 59.67% were females, and 40.33% were males; 91.93% attended school and 73.4% declared wanting to pursue university classes after turning 18. Adolescents from urban areas showed better medication managerial (p < 0.01) and tracking healthcare change skills. Significant correlations were found between medication and appointment making, tracking health dynamics, and communication skills. Other correlations were found between communication skills and medication knowledge, appointments management, and tracking healthcare dynamics. All the investigated domains were positively correlated with the overall scores, highlighting the potential impact of active targeted interventions during transition. Conclusions: We identified significant areas to address and potentially influence during an organized transition program such as communication skills and knowledge regarding the chronic disease and the followed medication.

Local Lidocaine-Prilocaine for Immunisation in Infants

Introduction: Lidocaine-prilocaine cream effectively reduces vaccination pain, improving vaccination adherence and advocating for its routine use in healthcare settings. Methods: This review used PRISMA guidelines and the PICOT format to structure the analysis. The focus was on paediatric patients aged 0-12 months requiring intramuscular vaccinations, comparing the application of lidocaine-prilocaine cream to other interventions or no treatment. Data sources included MEDLINE, PUBMED, EMBASE, BMC, Research GATE, and Cochrane Library. Studies were selected based on predefined inclusion and exclusion criteria, with data extracted regarding participant demographics, pain assessment scales, and study conclusions. The Cochrane Risk of Bias Tool assessed study quality, while statistical analyses evaluated the effectiveness of the intervention. Results: Fifty studies were identified, with nine ultimately included in the analysis, involving 704 participants. The primary outcome was the effectiveness of lidocaine-prilocaine cream in reducing pain after vaccinations. Results showed a significant mean difference of -1.719 in pain scores for infants treated with lidocaine-prilocaine compared to those receiving other interventions. Behavioural indicators, such as crying duration and latency to the first cry, favoured the lidocaine-prilocaine group. Conclusions: Lidocaine-prilocaine cream effectively reduces vaccination pain, supporting its routine use in healthcare settings. Engaging parents can enhance vaccination adherence. Training healthcare professionals on lidocaine-prilocaine cream application and pain scales is vital for improving patient satisfaction. Further research is needed to evaluate the long-term effects of lidocaine-prilocaine cream on vaccination experiences and infant behavioural health.

Patient's satisfaction level with community pharmacies services in Romania: a questionnaire-based study

INTRODUCTION

The patient satisfaction questionnaires in literature are according to the community pharmacies services in the authors' countries and not all have psychometric reports to support the results. We designed a questionnaire specific to the services of community pharmacies in Romania to evaluate the level of patient satisfaction.

METHODS

We carried out a cross-sectional study on voluntary patients. The questionnaire consisted of 22 items, grouped into three domains corresponding to patient satisfaction with pharmacies, pharmaceutical staff and medication availability, and four subdomains related to pharmaceutical staff skills. The 5-point Likert scale was used. Statistical analysis was done in SPSS 27.0.

RESULTS

The Cronbach's Alpha was 0.861. The Inter-rater Agreement was 72.0%, the Item Content Validity was 97.6% and the completeness index was 100%. The factor analysis indicated 6 factors (Eigen values >1.0). The 809 patients had a median of overall satisfaction score of 3.77; the median was 4.0 regarding satisfaction score with pharmaceutical staff skills. Respondents characteristics varied the patient's satisfaction level (p ≤ 0.05).

CONCLUSIONS

The reliability and validity of the questionnaire have been demonstrated. Overall patient satisfaction with community pharmacy services had a moderate level, but the attitude and confidence in the pharmacist had a high level of satisfaction.

Pediatric health service utilization at tertiary hospitals in Denmark 2000-2018

Pediatric health service differs between and within countries. To prioritize limited resources, data-driven studies on pediatric tertiary hospital contacts are warranted. This population-based register study identified all contacts with four Danish tertiary hospitals 2000-2018 by 0-17-year-old patients. During 2000-2018, 2,496,001 individuals resided in Denmark while 0-17 years old, and the study described 829,562 inpatient and 3,932,744 outpatient contacts at tertiary hospitals by hospital, sex, age, diagnosis, department, and residence. Male patients accounted for more contacts overall (inpatient 55.51%, outpatient 52.40%) and more contacts with severe chronic disease (inpatient 56.24%, outpatient 54.41%). Median (interquartile range) patient age was 3.09 (0.26-9.96) and 8.48 (2.78-13.70) years for in- and outpatient contacts. Overall, 28.23% and 21.02% of in- and outpatient contacts included a diagnosis of a severe chronic disease, but the proportions differed across hospitals. A pattern of pediatric healthcare directed towards less severe diseases was observed: While the total number of outpatient visits at tertiary hospitals increased from 2000 to 2018, the proportion of these contacts which had a diagnosis of a severe chronic disease decreased. Future comparisons between hospitals regarding pediatric outcomes should consider potential differences in terms of uptake and diagnosis severity. Such findings may have implications for future pediatric organization, nationally and internationally.

The Influence of Maternal Factors on Neonatal Intensive Care Unit Admission and In-Hospital Mortality in Premature Newborns from Western Romania: A Population-Based Study

Background and Objectives: Neonatal mortality is a global public health issue, disproportionately affecting low- and middle-income nations. Although Romania is a high-income nation, according to the European Union’s most recent demographic data, it had the second-highest infant death rate in 2019. Although significant progress has been made in the last three decades in lowering newborn mortality, more initiatives to accelerate progress are required to meet the 2030 Sustainable Development Goals (SDG) objective. Therefore, we aimed to develop an observational study to determine the influence of maternal factors on in-hospital neonatal intensive care unit admission and mortality in premature infants born in western Romania. While newborn mortality has decreased globally, the pace of decline is far less than what is desired. Materials and Methods: A retrospective study comprising 328 premature patients and 422 full-term newborns, was developed at a tertiary obstetrics and gynecology clinic in western Romania, comprising the period of the last 24 months before the COVID-19 pandemic and the first 24 months of the pandemic. Results: The following variables were identified as statistically significant risk factors for neonatal intensive care unit admission: age > 35 years, OR = 1.59; twin births, OR = 1.14; low gestational age, OR = 1.66; preeclampsia, OR = 2.33; and peripartum infection, OR = 2.25. The same risk factors, with the exception of twin births, were significantly associated with in-hospital neonatal mortality. Except for a longer duration of maternal hospitalization and neonatal therapy with surfactant, steroids, and antibiotics, the COVID-19 pandemic did not cause significant differences in the evolution and outcomes of preterm newborns. Conclusions: The major maternal risk factors for NICU admission were advanced age, twin pregnancy, low gestational age, preeclampsia, and peripartum infection. Additionally, these characteristics contributed to a high likelihood of death, despite adequate access to medical care and advanced life support for the neonates. Understanding the causes of morbidity and death in neonates admitted to the neonatal intensive care unit enables better prioritization and planning of health services, resource reallocation, and care quality improvement.

Challenges of paediatric palliative care in Romania: a focus groups study

BACKGROUND

The availability of palliative care facilities for children vary considerably among the European member states. In Romania, a country where health expenditure is among the lowest in Europe, palliative care has been mainly provided by charitable organizations. Despite the high number of children needing palliative care, there is scant literature and research available on paediatric palliative care in Romania. The study explores the viewpoints of various paediatric oncology providers with regard to paediatric palliative care provision in Romania.

METHODS

Four mixed focus groups were conducted at four university-affiliated paediatric oncology centres located in three distinct Romanian regions (Bucuresti-llfov, Nord-Est and Nord-Vest). The focus groups were analyzed using thematic coding.

RESULTS

For many healthcare professionals, emotional burden inherent to the profession; unhealthy work-life balance and understaffing were among the biggest barriers to the successful integration of pediatric palliative care. The lack of staff was attributed to a shortage of financial resources, and to the persisting cultural stigma surrounding palliative care and oncology. Also political turmoil was identified as an important obstacle to palliative care implementation.

CONCLUSION

Significant barriers persist limiting the broader implementation of pediatric palliative care in Romania. In order to render palliative care in pediatric oncology more sustainable, more attention should be paid to the mental health care of healthcare professionals working in this field, to the development of mobile palliative care services and to the emigration of skilled medical staff.

Vitamin D Status and Its Role in First-Time and Recurrent Urinary Tract Infections in Children: A Case-Control Study

Vitamin D has emerged as a key factor in innate immunity. Its involvement in the pathogenesis of urinary tract infections (UTIs) has gained a lot of attention recently. The objective of this study is to investigate the association between serum 25-hydroxyvitamin D (25(OH)D) levels and first-time or recurrent UTIs in children. A prospective, case-control study was conducted on 101 pediatric patients, who were divided into two groups: 59 patients with UTIs and 42 age-matched healthy controls. Serum 25(OH)D was determined in each child and expressed in ng/mL. Vitamin D presented significantly lower values in study group subjects than in healthy controls (p < 0.01). Moreover, a significantly higher prevalence of vitamin D insufficiency and deficiency was found in children with UTIs (p < 0.01). Patients with recurrent UTIs presented significantly lower levels of vitamin D than those with first-time UTIs (p = 0.04). Urinary tract abnormalities did not seem to exercise an additional effect upon vitamin D levels within the study group. In conclusion, first-time and recurrent UTIs are associated with lower vitamin D levels. Further studies are necessary to validate our findings, as well as future longitudinal research regarding efficacy of vitamin D supplementation in children with UTIs.

Prevalence of Underweight, Overweight and Obesity in School-Aged Children in the Urban Area of the Northwestern Part of Romania

INTRODUCTION

During the last three decades, there has been an excess weight epidemic due to changes in nutrition and lifestyle. Few data on the prevalence of overweight and obesity in children in Romania were published, without a single study representative at the national level. There are reports on the higher level of overweight and obesity in urban areas compared to rural ones. This study aimed to estimate the prevalence of underweight, overweight, obesity and severe obesity in children enrolled in schools from the urban area.

MATERIAL AND METHODS

For this cross-sectional study, children from 177 schools from the urban area of five counties from the northwestern part of Romania were included after the parents signed written informed consent. Anthropometric data were recorded (weight, height) based on World Health Organization (WHO) recommendations and Body-Mass-Index (BMI), and the z-score for BMI were calculated. The nutritional status was estimated using three reference criteria: WHO, International Obesity Task Force (IOTC) and the Center for Disease Control and Prevention (CDC).

RESULTS

We analyzed data of 21,650 children (48.19% boys) age between 7 and 18 years. The prevalence of overweight was 13.8%, 16.2% and 20.3%, of obesity was 10.7%, 10.0% and 5.7% and of severe obesity was 5.1%, 1.2% and 1.6% (using WHO, CDC and IOTF cut-offs). Underweight was present in 5.2% (WHO), 6% (CDC) and 2.6% (IOTF). The highest prevalence of overweight (including obesity) was found in children aged 10 years, and the lowest in adolescents at 18 years. Boys have a higher prevalence of excess weight than girls. Using IOTF cut-offs, the prevalence of obesity and severe obesity was lower than using WHO criteria.

CONCLUSIONS

The prevalence of overweight (including obesity) in children from the urban area of Western Romania was recorded at alarming levels, higher in boys and at the pre-puberty ages. There are significant differences based on the reference system used. It is important to correctly choose the reference for the definition of overweight and obesity to have the correct estimation of the target for public health measures.

Socio-Epidemiological Factors with Negative Impact on Infant Morbidity, Mortality Rates, and the Occurrence of Birth Defects

In the last 30-40 years, developed countries in particular, but also developing ones, have seen an increase in life expectancy and a decrease in infant mortality and morbidity rates. These factors are due to an increase in living standards, a decrease in differences between social classes, the increased accessibility of education to women, and the implementation of some public health measures. When certain basic social and medical measures are implemented on a large scale, their benefits are first reflected in lower infant mortality rates, and only in the second stage are such benefits reflected in decreasing neonatal mortality rates and a smaller number of stillbirths. In this study, we review the literature on these factors. We extrapolate and compare this literature with data recorded in our country in the hopes of finding the reasons why Romania ranks first in the European Union in terms of infant mortality rates. We found that lowering the infant morbidity, mortality, and congenital malformation rates is an absolute priority in Romania, which requires the involvement of decision makers in taking effective measures regarding food supplementation or enhancement using folic acid, adequate counselling of couples, monitoring of all pregnancies, setting antenatal diagnosis, implementing optimal delivery management and therapeutic approaches to problematic pregnancies in other hospitals and by involving the population in health education, avoiding occupational or in-home exposure to toxic factors, avoiding drug use, and implementing disease and infection prevention measures for pregnant women.