Childhood Obesity as a Global Problem: a Cross-sectional Survey on Global Awareness and National Program Implementation

Objective

The rising global epidemic of childhood obesity is a major public health challenge. Despite the urgency, there is a lack of data on the awareness and implementation of preventative measures. The aim of this study was to identify areas for improvement in the prevention and management of childhood obesity worldwide.

Methods

A cross-sectional electronic survey was distributed to 132 members of national pediatric societies of the International Pediatric Association.

Results

Twenty-eight (21.2%) participants, each from a different country across six World Health Organization (WHO) regions completed the survey. Most participants reported that national prevalence data of childhood obesity is available (78.6%), and the number increased during the Coronavirus disease-2019 pandemic (60.7%). In most countries (78.6%), the amount of sugar and salt in children’s products is provided but only 42.9% enacted regulations on children-targeted advertising. Childhood obesity prevention programs from the government (64.3%) and schools (53.6%) are available with existing support from private or non-profit organizations (71.4%). Participants were aware of WHO’s guidance concerning childhood obesity (78.6%), while fewer were aware of The United Nations International Children’s Emergency Fund’s (UNICEF) guidance (50%). Participants reported that WHO/UNICEF guidance acted as a reference to develop policies, regulations and national programs. However, progress was hindered by poor compliance. Lastly, participants provided suggestions on tackling obesity, with responses ranging from developing and reinforcing policies, involvement of schools, and prevention across all life stages.

Conclusion

There are different practices in implementing prevention measures to counter childhood obesity globally, particularly in statutory regulation on food advertising and national programs. While support and awareness was relatively high, implementation was hindered. This reflects the need for prompt, country-specific evaluation and interventions.

Healthcare provider perspectives on COVID-19 vaccination for children in India

BACKGROUND

The rapid development and deployment of effective COVID-19 vaccines have been critical to halt the spread of the pandemic. India started vaccinating children in early 2022, however, vaccine uptake has been suboptimal.

METHODS

Between September and November 2022, we conducted an online survey that was disseminated to eligible participants via email, text messages and social media platforms across India. The survey aimed to gather the perspectives of Indian healthcare providers regarding key factors related to the rollout of paediatric COVID-19 vaccines. Descriptive statistics were used to analyse participant demographics and responses on knowledge about paediatric COVID-19 vaccines, perceived risks and benefits, and vaccine rollout strategies.

RESULTS

The survey yielded 805 respondents from 23 Indian states; 63.5% were men, 97.3% were paediatricians, median age was 44 years (IQR 25-81). Eighty-one per cent and 65.2% respondents had heard about the most common paediatric COVID-19 vaccines in India, Covaxin and Corbevax, but only 52.9%, 53.7% and 62.1% felt adequately informed about their safety, efficacy and vaccination schedules, respectively. Thirty per cent of respondents were unaware of vaccination guidelines. Eighty-five per cent of respondents felt that vaccines would reduce the incidence of severe disease, hospitalisation and deaths, and 60.6% felt children with comorbidities should be prioritised for vaccination. Perceived supply side barriers included lack of enforcement of guidelines (45.2%) and adverse effects following immunisation monitoring systems (37.6%), and on the demand side, parental vaccine hesitancy (64.4%). Eighty-one per cent believed that school-based vaccination strategies would be highly effective in increasing uptake.

CONCLUSIONS

Most respondents were in support of the COVID-19 paediatric vaccination, although just over half did not feel adequately informed. Concerns about vaccine hesitancy among caregivers were the leading reported barrier. Targeted interventions are needed to provide adequate knowledge support to healthcare providers and evidence-based public health messaging to reduce vaccine hesitancy among caregivers.

Empowering Health Workers to Build Public Trust in Vaccination: Experience from the International Pediatric Association's Online Vaccine Trust Course, 2020-2021

BACKGROUND

The quality of interactions between health workers (HWs) and caregivers is key in vaccine acceptance. To optimize this, HWs need knowledge about best vaccine communication practices in person and on social media. Most pre-service curricula do not include such approaches. COVID-19 necessitated the International Pediatric Association (IPA) to shift from in-person train the trainer workshops to developing an online Vaccine Trust Course to address these gaps.

METHOD

The seven-module, 8-hour Vaccine Trust Course was offered online in seven languages and promoted globally. Course outcomes for participants between September 1, 2020 and September 30, 2021 were assessed using enrollment, participation, and completion data; pre-and post-training surveys of attitudes, knowledge, and practice skills; and follow-up practice surveys 3 months post course completion.

RESULTS

Of the 4,926 participants across 137 countries who registered; 2,381 (48.3 %) started the course, with 1,217 (51.1 %) completing. The majority were 25 - 39 years (57 %), female (57 %), and in pediatrics (70 %); 31 % came from India. 62 % of completers rated course structure/design as excellent, 36 % as good. Over 80 % rated the content as the most valuable aspect. Three months post training, 61 % HWs reported increased empathy towards caregivers, confidence while counseling and increased vaccine acceptance amongst their patients. 21 % identified the course as the only factor in these positive changes.

CONCLUSION

Shifting from face-to-face to online training due to the COVID-19 pandemic helped increase the global reach of HWs course engagement and uptake. Trained HWs reported increased empathy towards caregivers and confidence while counseling and increased patient vaccine acceptance.

Respiratory syncytial virus prevention within reach: the vaccine and monoclonal antibody landscape

Respiratory syncytial virus is the second most common cause of infant mortality and a major cause of morbidity and mortality in older adults (aged >60 years). Efforts to develop a respiratory syncytial virus vaccine or immunoprophylaxis remain highly active. 33 respiratory syncytial virus prevention candidates are in clinical development using six different approaches: recombinant vector, subunit, particle-based, live attenuated, chimeric, and nucleic acid vaccines; and monoclonal antibodies. Nine candidates are in phase 3 clinical trials. Understanding the epitopes targeted by highly neutralising antibodies has resulted in a shift from empirical to rational and structure-based vaccine and monoclonal antibody design. An extended half-life monoclonal antibody for all infants is likely to be within 1 year of regulatory approval (from August, 2022) for high-income countries. Live-attenuated vaccines are in development for older infants (aged >6 months). Subunit vaccines are in late-stage trials for pregnant women to protect infants, whereas vector, subunit, and nucleic acid approaches are being developed for older adults. Urgent next steps include ensuring access and affordability of a respiratory syncytial virus vaccine globally. This review gives an overview of respiratory syncytial virus vaccines and monoclonal antibodies in clinical development highlighting different target populations, antigens, and trial results.

Report of the 2nd workshop of the International Collaboration on advanced vaccinology training

At a workshop on 22-24 March 2022, leaders of 33 advanced vaccinology courses were invited to meet with partners to further the aims of the International Collaboration on Advanced Vaccinology Training (ICAVT) initiated in 2018 to assist courses in addressing challenges in priority areas and facilitate interactions and exchange of information. This included: an update to the landscape analysis of advanced vaccinology courses conducted in 2018, sharing experiences and good practices in the implementation of virtual training, reviewing the training needs of target audiences, informing courses of the principles, challenges, and added value of accreditation, discussing course evaluations and measurement of course impact, reviewing principles and support needed for quality cascade training, reviewing COVID-19 impact on training and identifying remaining related training needs, and identifying solutions to facilitate refresher courses and ways to facilitate networking of courses' alumni (particularly for virtual courses). The aims were to identify needs and impediments and implement necessary actions to facilitate sharing of information and resources between courses, to identify need for further developments of the e-Portal of the Collaboration (icavt.org) established to facilitate communication between the different courses and assist future course participants identify the most suitable course for them, and to discuss the formalization of the Collaboration. During the workshop, participants looked at several reports of surveys completed by courses and courses' alumni or partners. The COVID-19 pandemic impacted the delivery of some vaccinology courses leading to postponement, delivery online or hybrid training events. Lack of sustainable funding remained a major constraint for advanced vaccinology training and needs to be addressed. The Collaboration was consolidated with responsibilities and benefits for the members better defined. There was strong support for the Collaboration to continue with the organization of educational sessions at future workshops. The meeting re-enforced the view that there was much enthusiasm and commitment for the Global Collaboration and its core values.

A Public Health Research Agenda for Managing Infodemics: Methods and Results of the First WHO Infodemiology Conference

Background

An infodemic is an overflow of information of varying quality that surges across digital and physical environments during an acute public health event. It leads to confusion, risk-taking, and behaviors that can harm health and lead to erosion of trust in health authorities and public health responses. Owing to the global scale and high stakes of the health emergency, responding to the infodemic related to the pandemic is particularly urgent. Building on diverse research disciplines and expanding the discipline of infodemiology, more evidence-based interventions are needed to design infodemic management interventions and tools and implement them by health emergency responders.

Objective

The World Health Organization organized the first global infodemiology conference, entirely online, during June and July 2020, with a follow-up process from August to October 2020, to review current multidisciplinary evidence, interventions, and practices that can be applied to the COVID-19 infodemic response. This resulted in the creation of a public health research agenda for managing infodemics.

Methods

As part of the conference, a structured expert judgment synthesis method was used to formulate a public health research agenda. A total of 110 participants represented diverse scientific disciplines from over 35 countries and global public health implementing partners. The conference used a laddered discussion sprint methodology by rotating participant teams, and a managed follow-up process was used to assemble a research agenda based on the discussion and structured expert feedback. This resulted in a five-workstream frame of the research agenda for infodemic management and 166 suggested research questions. The participants then ranked the questions for feasibility and expected public health impact. The expert consensus was summarized in a public health research agenda that included a list of priority research questions.

Results

The public health research agenda for infodemic management has five workstreams: (1) measuring and continuously monitoring the impact of infodemics during health emergencies; (2) detecting signals and understanding the spread and risk of infodemics; (3) responding and deploying interventions that mitigate and protect against infodemics and their harmful effects; (4) evaluating infodemic interventions and strengthening the resilience of individuals and communities to infodemics; and (5) promoting the development, adaptation, and application of interventions and toolkits for infodemic management. Each workstream identifies research questions and highlights 49 high priority research questions.

Conclusions

Public health authorities need to develop, validate, implement, and adapt tools and interventions for managing infodemics in acute public health events in ways that are appropriate for their countries and contexts. Infodemiology provides a scientific foundation to make this possible. This research agenda proposes a structured framework for targeted investment for the scientific community, policy makers, implementing organizations, and other stakeholders to consider.

COVID-19 Pandemic: Knowledge and Perceptions of the Public and Healthcare Professionals

Background and objective

The recent pandemic due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a major concern for the people and governments across the world due to its impact on individuals as well as on public health. The infectiousness and the quick spread across the world make it an important event in everyone’s life, often evoking fear. Our study aims at assessing the overall knowledge and perceptions, and identifying the trusted sources of information for both the general public and healthcare personnel.

Materials and methods

This is a questionnaire-based survey taken by a total of 1,246 respondents, out of which 744 belonged to the healthcare personnel and 502 were laypersons/general public. There were two different questionnaires for both groups. The questions were framed using information from the World Health Organization (WHO), UpToDate, Indian Council of Medical Research (ICMR), Center for Disease Control (CDC), National Institute of Health (NIH), and New England Journal of Medicine (NEJM) website resources. The questions assessed awareness, attitude, and possible practices towards ensuring safety for themselves as well as breaking the chain of transmission. A convenient sampling method was used for data collection. Descriptive statistics [mean(SD), frequency(%)] were used to portray the characteristics of the participants as well as their awareness, sources of information, attitudes, and practices related to SARS-CoV-2.

Results

The majority (94.3%) of the respondents were Indians. About 80% of the healthcare professionals and 82% of the general public were worried about being infected. Various websites such as ICMR, WHO, CDC, etc., were a major source of information for the healthcare professional while the general public relied on television. Almost 98% of healthcare professionals and 97% of the general public, respectively, identified ‘Difficulty in breathing” as the main symptom. More than 90% of the respondents in both groups knew and practiced different precautionary measures. A minority of the respondents (28.9% of healthcare professionals and 26.5% of the general public) knew that there was no known cure yet. Almost all respondents from both the groups agreed on seeking medical help if breathing difficulty is involved and self-quarantine if required.

Conclusion

Most healthcare professionals and the general public that we surveyed were well informed about SARS-CoV-2 and have been taking adequate measures in preventing the spread of the same. There is a high trust of the public in the government. There are common trusted sources of information and these need to be optimally utilized to spread accurate information.

Epidemiology of blood stream infections in pediatric patients at a Tertiary Care Cancer Centre

BACKGROUND

Blood stream infections (BSI) are among the most common causes of preventable deaths in children with cancer in a developing country. Knowledge of its etiology as well as antibiotic sensitivity is essential not only for planning antimicrobial policy, but also the larger infection prevention and control measures.

AIMS

To describe the etiology and sensitivity of BSI in the pediatric oncology unit at a tertiary cancer center.

MATERIALS AND METHODS

All the samples representative of BSI sent from pediatric oncology unit during the period of January to December, 2013 were included in the study, and analyzed for microbiological spectrum with their antibiotic sensitivity.

RESULTS

A total of 4198 samples were representative of BSI. The overall cultures positivity rate was 6.97% with higher positivity rate (10.28%) from central lines. Of the positive cultures, 208 (70.9%) were Gram-negative bacilli (GNB), 71 (24.2%) were Gram-positive organisms, and 14 (4.7%) were Candida species. Lactose fermenting Enterobacteriaceae i.e., Escherichia coli (28.4%), Klebsiella pneumoniae (22.1%), and Enterobacter (4.8%) accounted for 55.3% of all GNB. Pseudomonas accounted for 53 (25.5%) and Acinetobacter 19 (9.1%) of GNB. Among Gram-positive isolates, staphylococci were the most frequent (47.8%), followed by Streptococcus pneumoniae 17 (23.9%), beta-hemolytic streptococci 11 (15.5%), and enterococci 9 (12.68%). Of GNB, 45.7% were pan-sensitive, 24% extended spectrum beta-lactamase (ESBL) producers, 27% were resistant to carbapenems, and 3.4% resistant to colistin. Pseudomonas was most sensitive, and Klebsiella was least sensitive of GNB. Of the staphylococcal isolates, 41.67% were methicillin-resistant Staphylococcus aureus (MRSA) and 10% of Coagulase Negative Stapylococci (CONS) were methicillin.

CONCLUSION

A high degree of ESBL producers and carbapenem-resistant Enterobacteriaceae is concerning; with emerging resistance to colistin, raising the fear of a return to the preantibiotic era. An urgent intervention including creating awareness and establishment of robust infection control and antibiotic stewardship program is the most important need of the hour.

Alarming prevalence of community-acquired multidrug-resistant organisms colonization in children with cancer and implications for therapy: A prospective study

BACKGROUND

Infection or colonization with multidrug-resistant organisms (MDRO) is associated with high mortality and morbidity. Knowledge of MDRO colonization may help in planning empirical antibiotic approach in neutropenic patients, which is known to improve patient outcomes. While routine cultures are positive and may help direct antibiotic therapy in only up to 15% neutropenic patients, surveillance cultures are positive in more than 90% of cancer patients.

AIMS

To assess the rate of MDRO carrier status at presentation and rate of conversion to MDRO during the treatment.

MATERIALS AND METHODS

Rectal swabs of all the outpatients presenting to pediatric oncology unit were sent within 7 days from date of registration from January 2014 to December 2014. Furthermore, stool cultures/rectal swabs of all patients who got directly admitted to the pediatric ward at presentation were sent within 24 h. Repeat rectal swabs were sent again for patients from this cohort when they got readmitted to the ward at least 15 days after last discharge or when clinically indicated.

RESULTS

Baseline surveillance rectal swabs were sent for 618 patients, which included 528 children with hematological malignancies and 90 children with solid tumors. Forty-five (7.3%) showed no growth. Of the remaining 573, 197 (34.4%) patients were colonized by two organisms and 30 (5.2%) by three organisms. Three hundred and thirty-four (58.4%) showed extended spectrum beta-lactamase (ESBL) Enterobacteriaceae, of which 165 (49.5%) were ESBL sensitive to beta-lactam with beta-lactamase inhibitors combinations and 169 (50.5%) were resistant to combinations. One hundred and sixteen (20.2%) were carbapenem-resistant Enterobacteriaceae (CRE) and 65 (11.4%) had vancomycin-resistant enterococci in baseline cultures. Only 63 (21%) patients were colonized by a sensitive organism in their baseline surveillance cultures. Morbidity (Intensive Care Unit stay) and mortality was higher in patients colonized by MDR organisms. There was a significant correlation between the place of residence and CRE colonization status with the highest rate (60%) of CRE colonization observed in children from East India. The repeat cultures showed the further conversion of sensitive isolates to MDRO in 80% of these children, of which 40% each converted from non-ESBL and non-CRE to ESBL and CRE, respectively.

CONCLUSION

This is the first study illustrating the alarming high prevalence of community-acquired MDRO colonization, especially CRE, which has grave implications for therapy for children with cancer potentially compromising delivery of aggressive chemotherapy and affecting outcomes. This incidence further increases during the course of treatment. Knowing the baseline colonization also guides us for the planning of chemotherapy as well as antibiotic approach and infection control strategies. Local antibiotics stewardship including education of the healthcare workers as well as national level interventions to prevent antibiotic misuse in the community is critical to minimize this problem.

Role of Global Alliance for Vaccines and Immunization (GAVI) in Accelerating Inactivated Polio Vaccine Introduction

Global Alliance for Vaccines and Immunization (GAVI, the Vaccine Alliance) is an international organization built through public-private partnership. GAVI has supported more than 200 vaccine introductions in the last 5 years by financing major proportion of costs of vaccine to 73 low-income countries using a co-financing model. GAVI has worked in close co-ordination with Global Polio Eradication Initiative (GPEI) since 2013, to strengthen health systems in countries so as to accelerate introduction of inactivated polio vaccine (IPV). GAVI is involved in many IPV related issues like demand generation, supply, market shaping, communications, country readiness etc. Most of the 73 GAVI eligible countries are also high priority countries for GPEI. GAVI support has helped India to accelerate introduction of IPV in all its states. However, GAVI faces challenges in IPV supply-related issues in the near future. It also needs to play a key role in global polio legacy planning and implementation.

Global Polio Eradication,The Journey So Far

The Global Polio Eradication Initiative (GPE I), since its launch in 1988 has achieved more than 99% reduction in polio cases globally, using oral polio vaccine (OPV). Currently only two countries (Pakistan and Afghanistan) have not been able to stop transmission of wild poliovirus (wPV). In this article, we discuss some of the challenges faced by these two countries. The lessons learnt from the tremendous public health success stories of India and Nigeria are also highlighted. Reintroduction of wPV in the polio-free areas remains a valid risk globally and some recent examples are discussed. Inactivated polio vaccine (IPV) is the most accepted risk-mitigation strategy to secure a polio-free world from both wPV and circulating vaccine derived poliomyelitis (VDPV). The challenges related to switch from trivalent to bivalent OPV and introduction of IPV in 156 countries using trivalent OPV, are also highlighted.

Ending preventable newborn deaths in a generation

The end of the Millennium Development Goal (MDG) era was marked in 2015, and while maternal and child mortality have been halved, MGD 4 and MDG 5 are off-track at the global level. Reductions in neonatal death rates (age <1 month) lag behind those for post-neonates (age 1-59 months), and stillbirth rates (omitted from the MDGs) have been virtually unchanged. Hence, almost half of under-five deaths are newborns, yet about 80% of these are preventable using cost-effective interventions. The Every Newborn Action Plan has been endorsed by the World Health Assembly and ratified by many stakeholders and donors to reduce neonatal deaths and stillbirths to 10 per 1000 births by 2035. The plan provides an evidence-based framework for scaling up of essential interventions across the continuum of care with the potential to prevent the deaths of approximately three million newborns, mothers, and stillbirths every year. Two million stillbirths and newborns could be saved by care at birth and care of small and sick newborns, giving a triple return on investment at this key time. Commitment, investment, and intentional leadership from global and national stakeholders, including all healthcare professionals, can make these ambitious goals attainable.

Indian Academy of Pediatrics (IAP) recommended immunization schedule for children aged 0 through 18 years--India, 2014 and updates on immunization

JUSTIFICATION

There is a need to review/revise recommendations about existing vaccines in light of recent developments in the field of vaccinology.

PROCESS

Following an IAP ACVIP meeting on April 19 and 20, 2014, a draft of revised recommendations for the year 2014 and updates on certain vaccine formulations was prepared and circulated among the meeting participants to arrive at a consensus.

OBJECTIVES

To review and revise recommendations for 2014 Immunization timetable for pediatricians in office practice and issue statements on certain new and existing vaccine formulations.

RECOMMENDATIONS

The major changes in the 2014 Immunization Timetable include two doses of MMR vaccine at 9 and 15 months of age, single dose recommendation for administration of live attenuated H2 strain hepatitis A vaccine, inclusion of two new situations in high-risk category of children in context with pre-exposure prophylaxis of rabies, creation of a new slot at 9-12 months of age for typhoid conjugate vaccine for primary immunization, and recommendation of two doses of human papilloma virus vaccines with a minimum interval of 6 months between doses for primary schedule of adolescent/preadolescent girls aged 9-14 years. There would not be any change to the committee's last year's (2013) recommendations on pertussis vaccination and administration schedule of monovalent human rotavirus vaccine. There is no need of providing additional doses of whole-cell pertussis vaccine to children who have earlier completed their primary schedule with acellular pertussis vaccine-containing products. A brief update on the new Indian Rotavirus vaccine, 116E is also provided. The committee has reviewed and offered its recommendations on the currently available pentavalent vaccine (DTwP+Hib+Hepatitis-B) combinations in Indian market. The comments and footnotes for several vaccines are also updated and revised.

Assessing providers' vaccination behaviors during routine immunization in India

Progress has been made toward improving routine immunization coverage in India, but universal coverage has not been achieved. Little is known about how providers' vaccination behaviors affect coverage rates. The purpose of this study was to identify provider behaviors that served as barriers to vaccination that could lead to missed opportunities to vaccinate. We conducted a study of health-care providers' vaccination behaviors during clinic visits for children <3 years of age. Information on provider behaviors was collected through parent report and direct observation. Compared with illness visits, parents were eight times more likely to report vaccination status was verified (p < 0.001) and three times more likely to report receiving counseling on immunization (p = 0.022) during vaccination visits. Training of all vaccination practitioners should focus on behaviors such as the necessity of verifying vaccination status regardless of visit type, stressing the importance of counseling parents on immunization and emphasizing what is a valid contraindication to vaccination.

Pediatricians' perspectives on pneumococcal conjugate vaccines: An exploratory study in the private sector

There is a lack of information on supply-side determinants, their utilization, and the access to pneumococcal vaccination in India. The objective of this exploratory study was to document the perceptions and perspectives of practicing pediatricians with regard to pneumococcal conjugate vaccines (PCVs) in selected metropolitan areas of India. A qualitative study was conducted to generate evidence on the perspective of pediatricians practicing in the private sector regarding pneumococcal vaccination. The pediatricians were identified from 11 metropolitan areas on the basis of PCV vaccine sales in India through multilevel stratified sampling method. Relevant information was collected through in-depth personal interviews. Finally, qualitative data analysis was carried out through standard techniques such as the identification of key domains, words, phrases, and concepts from the respondents. We observed that the majority (67.7%) of the pediatricians recommended pneumococcal vaccination to their clients, whereas 32.2% recommended it to only those who could afford it. More than half (62.9%) of the pediatricians had no preference for any brand and recommended both a 10-valent pneumococcal conjugate vaccine (PCV10) and a 13-valent PCV (PCV13), whereas 8.0% recommended none. An overwhelming majority (97.3%) of the pediatricians reported that the main reason for a patient not following the pediatrician's advice for pneumococcal vaccination was the price of PCV. To reduce childhood pneumonia-related burden and mortality, pediatricians should use every opportunity to increase awareness about vaccine-preventable diseases, especially vaccine-preventable childhood pneumonia among their patients.

More evidence on the impact of India's conditional cash transfer program, Janani Suraksha Yojana: quasi-experimental evaluation of the effects on childhood immunization and other reproductive and child health outcomes

BACKGROUND

In 2005, India established a conditional cash transfer program called Janani Suraksha Yojana (JSY), to increase institutional delivery and encourage the use of reproductive and child health-related services.

OBJECTIVE

To assess the effect of maternal receipt of financial assistance from JSY on childhood immunizations, post-partum care, breastfeeding practices, and care-seeking behaviors.

METHODS

We use data from the latest district-level household survey (2007-2008) to conduct a propensity score matching analysis with logistic regression. We conduct the analyses at the national level as well as separately across groups of states classified as high-focus and non-high-focus. We carry out several sensitivity analyses including a subgroup analysis stratified by possession of an immunization card.

RESULTS

Receipt of financial assistance from JSY led to an increase in immunization rates ranging from 3.1 (95%CI 2.2-4.0) percentage points for one dose of polio vaccine to 9.1 (95%CI 7.5-10.7) percentage points in the proportion of fully vaccinated children. Our findings also indicate JSY led to increased post-partum check-up rates and healthy early breastfeeding practices around the time of childbirth. No effect of JSY was found on exclusive breastfeeding practices and care-seeking behaviors. Effect sizes were consistently larger in states identified as being a key focus for the program. In an analysis stratified by possession of an immunization card, there was little to no effect of JSY among those with vaccination cards, while the effect size was much larger than the base case results for those missing vaccination cards, across nearly all immunization outcomes.

CONCLUSIONS

Early results suggest the JSY program led to a significant increase in childhood immunization rates and some healthy reproductive health behaviors, but the structuring of financial incentives to pregnant women and health workers warrants further review. Causal interpretation of our results relies on the assumption that propensity scores balance unobservable characteristics.

The impact of polio eradication on routine immunization and primary health care: a mixed-methods study

Background. After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC).

Methods. Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review.

Results. Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year.

Conclusions. Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts.

Attitudes and practices of auxiliary nurse midwives and accredited social health activists in Uttar Pradesh and Bihar regarding polio immunization in India

Although India was removed from the list of polio endemic countries in January 2012, maintaining the focus on polio vaccination is critically important to prevent reintroduction of the virus. In 2009-2010, we conducted a study to assess the attitudes and practices of frontline health workers in India regarding polio immunization in Uttar Pradesh and Bihar. More than 95% of auxiliary nurse midwives (ANMs) and accredited social health activists (ASHAs) agreed that polio supplementary immunization campaigns helped in increasing acceptance of all vaccines. The majority of ANMs (60-70%) and ASHAs (56-71%) believed that polio immunization activities benefitted or greatly benefitted other activities they were carrying out. Less than 5% of ANMs and ASHAs felt they were very likely to face resistance when promoting or administering polio vaccine. This study provides information that may be useful for programs in other countries for polio eradication and in India for measles elimination.

Pediatricians' perceptions of vaccine effectiveness and safety are significant predictors of vaccine administration in India

BACKGROUND

New vaccine introduction is important to decrease morbidity and mortality in India. The goal of this study was to identify perceptions that are associated with administration of four selected vaccines for prevention of Japanese encephalitis (JE), typhoid fever, influenza and human papillomavirus (HPV) infection.

METHODS

A random sample of 785 pediatricians from a national list of Indian Academy of Pediatrics members was selected for a survey to assess perceptions of vaccine effectiveness and safety, and vaccine administration practices. Logistic regression was used to assess factors associated with selective or routine use.

RESULTS

Pediatricians reported administering typhoid (91.6%), influenza (60.1%), HPV (46.0%) and JE (41.9%) vaccines selectively or routinely. Pediatricians who perceived the vaccine to be safe were significantly more likely to report administration of JE (OR 2.6, 95% CI 1.3 to 5.3), influenza (OR 4.3, 95% CI 2.0 to 9.6) and HPV vaccine (OR 6.2, 95% CI 3.1 to 12.7). Pediatricians who perceived the vaccine to be effective were significantly more likely to report administration of JE (OR 3.3, 95% CI 1.6 to 6.5), influenza (OR 7.7, 95% CI 2.5 to 23.1) and HPV vaccine (OR 3.2, 95% CI 1.6 to 6.4) CONCLUSION: Understanding the role perceptions play provides an opportunity to design strategies to build support for vaccine use.

Haemophilus influenza type b disease and vaccination in India: knowledge, attitude and practices of paediatricians

BACKGROUND

Haemophilus influenza type b (Hib) causes significant morbidity and mortality among young children in India. Hib vaccines are safe and efficacious; nevertheless, their introduction to India's national immunization programme has been hindered by resistance from certain sectors of academia and civil society. We aimed to ascertain the attitudes and perceptions of Indian paediatricians towards Hib disease and vaccination.

MATERIALS AND METHODS

A cross-sectional survey of knowledge, attitude and practices on Hib and vaccines was undertaken among 1000 Indian paediatricians who attended 49 th National Conference of Indian Academy of Pediatrics in 2012 through use of a 21-point questionnaire.

RESULTS

927 (93%) paediatricians completed the survey. 643 (69%) responded that Hib is a common disease in India. 788 (85%) reported prescribing Hib vaccine to their patients and 453 (49%) had done so for the past 5-15 years. Hib vaccine was used in combination with other vaccines by 814 (88%) of the participants. 764 (82%) respondents thought Hib vaccine effective while 750 (81%) thought it to be safe. Fever, pain and redness were the most frequently reported post vaccination side-effects. 445 (48%) paediatricians ranked universal use of Hib vaccine in the national immunization programme as the most important strategy to prevent and control Hib disease in India.

CONCLUSION

The excellent profile as reported by a large number of paediatricians from throughout India further strengthens evidence to support expanded use of currently available Hib vaccines. These findings should encourage the Government of India to initiate mass use of this vaccine nationwide.

Predictors of administration and attitudes about pneumococcal, Haemophilus influenzae type b and rotavirus vaccines among pediatricians in India: a national survey

INTRODUCTION

According to the World Health Organization in 2008, pneumonia accounted for 20% of deaths and diarrheal diseases accounted for 13% of deaths among children under 5 in India. Vaccines are available for Streptococcus pneumoniae (pneumococcal conjugate vaccine (PCV)), Haemophilus influenzae type b (Hib vaccine), and rotavirus. Barriers to including these vaccines in routine immunization schedule in India include potential negative impacts on fragile existing immunization programs and cost. Pediatricians who are members of the Indian Academy of Pediatrics (IAP) are important stakeholders for vaccine delivery and maintaining public confidence in vaccines.

METHODS

A random sample of 785 pediatricians belonging to IAP was selected for the survey conducted from June 2009 to June 2010. Descriptive analyses using sampling weights were performed to evaluate the distributions of variables assessing vaccine-related attitudes and behaviors among pediatricians. Logistic regression was used to assess factors associated with routine vaccine use.

RESULTS

The majority of pediatricians reported administering PCV (85.6%), Hib (95.9%), and rotavirus (80.2%) vaccine selectively or routinely. Pediatricians who had high perceived disease susceptibility were 2.42 times more likely to report routine administration of Hib vaccine (OR 2.42, 95% CI 1.24, 4.74). Pediatricians who had high perceived Hib vaccine efficacy were 4.74 times more likely to administer Hib vaccine routinely (OR 4.74, 95% CI 2.09, 10.74). Perceptions of disease susceptibility and severity or of vaccine safety and efficacy were not associated with routine administration of PCV or rotavirus vaccine.

CONCLUSIONS

Understanding predictors of routine use of a new vaccine could help focus interventions to improve the routine use of other vaccines. The importance of perceived susceptibility to and severity of diseases caused by S. pneumoniae, Hib, and rotavirus and perceived efficacy and safety of the vaccines by pediatricians presents an opportunity to design strategies to build support for new vaccine introduction and may have important implications for national immunization policy in India.

Recommendations of 2nd National Consultative Meeting of Indian Academy of Pediatrics (IAP) on polio eradication and improvement of routine immunization

JUSTIFICATION

Persistence of intense wild poliovirus (WPV) transmission, particularly type 3 in northern India necessitated the Indian Academy of Pediatrics (IAP) to convene a National Consultative Meeting to review its earlier recommendations on polio eradication and improvement of routine immunization.

PROCESS

More than thirty experts were invited and intense deliberations were held over two days to draw consensus statements on various issues related with polio eradication.

OBJECTIVES

To review the ongoing strategy, identify the existing challenges, and suggest modifications to the current strategy for eradication of poliomyelitis in India.

RECOMMENDATIONS

IAP reiterates its support to ongoing efforts on polio eradication but demand some flexibility in the strategy. The immediate challenges identified include persistent WPV type 1 transmission in Uttar Pradesh (UP) and Bihar, intense type 3 transmission also in UP and Bihar, and maintaining polio-free status of all other states. Circulating vaccine derived poliovirus (cVDPV), particularly type 2, was identified as a great future threat. Neglect of routine immunization (RI), poor efficacy of oral polio vaccine (OPV), operational issues, and inadequate uptake of OPV in the 2 endemic states are the main reasons of failure to interrupt transmission of WPV 1 and 3. However, for the first time in history the intensity of WPV 1 circulation is very low in western UP. IAP suggests that high-quality, uniform and consistent performance of supplementary immunization activities (SIAs) in all districts of western UP, particularly using mOPV1(monovalent OPV1) should be maintained to avoid reestablishment of circulation of type 1 poliovirus. A judicious mix of mOPV1 and mOPV3, given sequentially or even simultaneously (after validating the efficacies) will be necessary to address the upsurge of WPV3. Re-establishing routine immunization should be the foremost priority. IAP strongly recommends to Government of India (GOI) to take urgent measures to attain coverage of a minimum of 90% against all UIP antigens in all the states by the end of 2008. In view of the need to simultaneously raise immunity levels to protect against WPVs 1, 3 and cVDPV2, IPV may be given immediate consideration as an additional tool. IPV will be essential in the postWPVeradication phase; it can play a useful role even in the current WPV eradication phase. IAP urges the GOI to urgently sort out various issues associated with implementation of the proposal to use IPV. More transparency is needed on cases of vaccine associated paralytic poliomyelitis (VAPP). Further improvement in stool collection rates is also warranted to minimize the tally of compatible cases. IAP urges the social mobilization network to address the issues of waning interest and shifting focus and negative media coverage. Alternate tactics like reduced numbers of SIAs applied in the low transmission season, along with IPVDTP combination vaccine in RI can also be considered. IAP believes it will be risky to stop vaccination against poliomyelitis in postWPV eradication phase. The best option is to gradually introduce IPV starting now, so that a switch to IPV following high-performance national immunization days (NIDs) can be made to ensure sustained high immunity against all polioviruses, wild and vaccine derived. IAP requests the global polio eradication initiative (GPEI) to continue relevant research to inform on various aspects related to polio eradication, defined as zero incidence of any poliovirus infection. IAP also urges GOI to take immediate measures for improvement of environmental sanitation.

Brain-derived neurotrophic factor polymorphism Val66Met influences cognitive abilities in the elderly

A functional brain-derived neurotrophic factor (BDNF) gene polymorphism (Val66Met) that alters activity-dependent secretion has previously been reported to influence cognitive functioning. A large proportion of these reports suggest that the Met allele, which results in reduced secretion of BDNF, impairs long-term memory as a direct consequence of its influence on hippocampal function but has little influence on working memory. In contrast, other studies have found that the Met allele can also play a protective role in certain neurological conditions and is associated with improved non-verbal reasoning skills in the elderly suggesting effects that appear disease, domain and age specific. We have investigated six haplotype-tagging single nucleotide polymorphisms (SNPs) using a cohort of 722 elderly individuals who have completed cognitive tests that measured the domains of fluid intelligence, processing speed and memory. We found that the presence of the Met allele reduced cognitive performance on all cognitive tests. This reached nominal significance for tests of processing speed (P = 0.001), delayed recall (P = 0.037) and general intelligence (g) (P = 0.008). No association was observed between cognitive tests and any other SNPs once the Val66Met was adjusted for. Our results support initial findings that the Met allele is associated with reduced cognitive functioning. We found no evidence that the Met allele plays a protective role in older non-demented individuals. Magnetic resonance imaging data collected from a subgroup of 61 volunteers showed that the left and right hippocampus were 5.0% and 3.9% smaller, respectively, in those possessing the Met allele, although only a non-significant trend was observed.

Balance marks cognitive changes in old age because it reflects global brain atrophy and cerebro-arterial blood-flow

In healthy old age biomarkers such as Balance robustly correlate with measures of mental abilities such as scores on tests of intelligence, reaction times and memory. A plausible explanation is that balance reflects general physiological fitness and so also neurophysiological integrity, but direct evidence is lacking. Brain scans measured age-associated loss of brain volume and cerebro-arterial blood flow (CBf) in 69 volunteers aged from 62 to 81 years who also took the Tinetti Balance test battery, 3 tests of fluid intelligence, 3 tests of decision speed and a memory test. Balance, but not atrophy or CBf, predicted intelligence test scores. Balance, atrophy, and CBf all independently predicted speed and memory scores but, after variance in atrophy and CBf had been considered, predictions from Balance were no longer significant. It appears that in these tests Balance marks cognitive performance in old age because it reflects gross age-related neurophysiological changes.

Current status of polio eradication and future prospects

The launch and the progress of global polio eradication initiative lead to a world wide decline of polio cases during the last few years. India shared this progress till 2001, when the number of reported cases were 268. Reversing this trend India reported 1599 cases during 2002 thereby accounting for nearly 87% of cases detected globally. Strategies for polio eradication are being revised after realizing that strategies such as fixed booth approach have not been sufficient to interrupt wild polio virus transmission. Increased number of NIDs and additional SNIDs are being planed to reach the previously unreached children. Low literacy levels, high poverty and resistance for OPV immunization in certain areas has further compounded the problem. As the progress in India is critical for the global polio eradication, maintenance of high routine immunization coverage, monitoring of SIA quality, AFP surveillance and laboratory investigations are vital for a successful outcome of this initiative.

Treatment response in late-onset depression: relationship to neuropsychological, neuroradiological and vascular risk factors

BACKGROUND

Late-onset depressive disorder is associated with white matter lesions and neuropsychological deficits that in some studies are linked to a poorer outcome for depression. Some white matter lesions may be vascular in origin. This study investigated the relationship between response or non-response to antidepressant monotherapy and neuropsychological function, structural brain measures and vascular factors.

METHOD

This was a case control study. Fifty patients with late-onset major depressive disorder (29 who were responders to antidepressant monotherapy and 21 who were not) were compared with 35 non-depressed control subjects. Measures included assessment of vascular risk factors, neuropsychological testing and a magnetic resonance imaging (MRI) scan.

RESULTS

After adjustment for depressed mood and medication at evaluation, both patient groups had significantly more impairment compared to control subjects on verbal learning tasks involving immediate or delayed recall. Patients who did not respond to antidepressant monotherapy had significantly poorer performance than controls on tests involving visuospatial ability, language, word recognition and tests of executive function, whereas there were no differences between control subjects and responders. On two tests of executive function (verbal fluency and the Stroop test) non-responders scored significantly worse than responders. There were no significant group differences on MRI measures of atrophy or of white matter lesions apart from a higher periventricular hyperintensity score in non-responders compared to controls. There were no group differences on measures of vascular disease.

CONCLUSION

The results lend support to the emerging evidence that resistance to treatment in late-onset depression may be associated with impaired executive function. Subtle cerebrovascular mechanisms may be involved.

Right-hemisphere encephalopathy in elderly subjects with schizophrenia: evidence from neuropsychological and brain imaging studies

RATIONALE

Cognitive impairment is a recognised feature of schizophrenia. Elderly patients with early-acquired schizophrenia are seriously affected, with a proportion of them showing clinically significant dementia, not accounted for by any recognized degenerative processes common in this age group, such as Alzheimer's disease. Progression of cognitive deficits is described in elderly institutionalised patients, but disputed amongst community dwelling subjects. The pattern of cognitive deficits in this age group is not yet clearly defined, although there is some evidence that it differs from that in Alzheimer's disease. There is little evidence of any underlying specific brain abnormality.

OBJECTIVES

To characterize the neuropsychological deficits in elderly schizophrenia patients and distinguish them from those in Alzheimer's disease. To establish the presence of underlying structural brain abnormality using MRI.

METHODS

Twenty-eight elderly schizophrenia patients with onset before the age of 45 years carried out neuropsychology tests. Twelve scored in the dementia range and were compared with 16 equally impaired patients with early Alzheimer's disease. Thirteen of the schizophrenia patients consented to brain MRI. The imaging data were analysed using a newly developed automated method of measuring CSF volume distributions and compared with data from 30 age-matched normal controls.

RESULTS

The schizophrenia group was more impaired on visuo-spatial tasks than the Alzheimer's group but less impaired on corresponding verbal tasks, despite similar overall cognitive impairment. The MR scans revealed right-sided enlargement of ventral CSF spaces in the schizophrenia patients especially in the posterior third, and this correlated with their impaired performance on visuo-spatial tasks.

CONCLUSIONS

The results suggest that right hemisphere impairment underlies the specific profile of cognitive impairment in elderly patients with schizophrenia.