Knowledge Attitude and Practice of Mothers with Under-Five Children about Immunization

Introduction: Vaccines are one of most successful healthinterventions that bring about significant reduction ininfectious diseases and adverse health consequences. In India,The Expanded Program on Immunization (EPI) was launchedin 1978 and it was re-designated as the Universal Immunizationprogram (UIP) in 1985, with a goal to cover at least 85% ofinfants. In India 7.4 million children are not immunized. Studyaimed to determine the knowledge, attitude and practice ofmothers with under five children about immunization.Material and methods: Research was conducted to determinethe knowledge attitude and practice of mothers with underfive children about immunization. A cross sectional study wasconducted among mothers having children aged more thantwo and half years in the field practice area of K.S. HegdeMedical Academy. Data was collected using a pre-tested semistructured questionnaire from 348 mothers during a periodof two months. Among the study participants (92) 26% werefrom urban area and (256) 74% were from rural area. Motherswere the main decision makers regarding vaccination of thechild in both urban and rural areas.Results: Majority 99% supported vaccination. Majority 97%of the mothers in both the urban and rural areas believedthat vaccines were protective. In the study it was seen that93% of the mothers had vaccinated their children as pervaccination card and the rest of the mothers were not upto date with vaccinating their children. Only 43%of themothers were aware of the side effects and 32% knew aboutcontraindications. In this study it was found that 32% of themothers believed that vaccination could be done even if thechild had fever. Only 22% of the mothers were aware of theSMS notification program by the government.Conclusion: In the study the reasons stated by the mothersfor not fully vaccinating the child were because of the sideeffects 44%, difficulty in reaching the center 28% and longcrowds 19%.According to our study, majority of the motherswere supportive of immunizing their children but unaware oftheir contraindications and side effects.

Current costs & projected financial needs of India’s Universal Immunization Programme.

Background & objectives: India’s Universal Immunization Programme (UIP) is one of the largest programmes in the world in terms of quantities of vaccines administered, number of beneficiaries, number of immunization sessions, and geographical extent and diversity of areas covered. Strategic planning for the Programme requires credible information on the cost of achieving the objectives and the financial resources needed at national, State, and district levels. We present here expenditures on immunization services in India in 2012 (baseline) and projected costs for five years (2013-2017). Methods: Data were collected from the Immunization Division of the Ministry of Health and Family Welfare, Government of India, and immunization partners, such as the World Health Organization and UNICEF. The cost components were immunization personnel, vaccines and injection supplies, transportation, trainings, social mobilization, advocacy and communication activities, disease surveillance, Programme management, maintenance of cold chain and other equipment, and capital costs. Results: Total baseline expenditure was ` 3,446 crore [1 crore = 10 million] (US$718 million), including shared personnel costs. In 2012, the government paid for 90 per cent of the Programme. Total resource requirements for 2013-2017 are ` 34,336 crore (US$ 5, 282 million). Allocations for vaccines increase from ` 511 crore in 2013 to ` 3,587 crore in 2017 as new vaccines are assumed to be introduced in the Programme. Interpretation & conclusions: The projections show that the government immunization budget will be double in 2017 as compared to 2013. It will increase from ` 4,570 crore in 2013 to ` 9,451 crore in 2017.

Assessment of immunization status of 1000 children attending pediatric OPD of a teaching hospital in Ahmedabad.

Objective: Assessment of immunization status of children attending Pediatric OPD of a tertiary care hospital and the common causes for not giving the vaccines on time. Methods: A cross sectional study was performed with the help of a semi- structured questionnaire. Vaccination status was confirmed referring to the records of immunization available with the mothers. Site and age-specific details of the vaccines administered were also probed to ascertain the vaccine given whenever required. Results: Immunization coverage was 52.7% which was less than the national average of 61%. Coverage was highest for BCG and OPV zero vaccines (94.4%). Significant reductions in the coverage of the first and third doses of DPT, OPV and Hepatitis B vaccine were observed. There was absolutely no coverage of dT/ TT vaccine. Most common reasons for denial of vaccination were found to be negligence (35.8%) and ignorance (14.8%). The immunization coverage was higher in residents of rural areas (72.32%) and in children of literate mothers (76%). There was no significant reduction in eventual booster doses of DPT. Conclusions: Day by day, universal immunization is increasing but gaps are still visible even at tertiary care settings. Efforts are needed to strengthen the already existing policies. Aggressive sensitization and behaviour change drives targeting mothers can go a long way in achieving the same.

Comparison of Usual Interstitial Pneumonia and Nonspecific Interstitial Pneumonia: Quantification of Disease Severity and Discrimination between Two Diseases on HRCT Using a Texture-Based Automated System

OBJECTIVE: To evaluate the usefulness of an automated system for quantification and discrimination of usual interstitial pneumonia (UIP) and nonspecific interstitial pneumonia (NSIP). MATERIALS AND METHODS: An automated system to quantify six regional high-resolution CT (HRCT) patterns: normal, NL; ground-glass opacity, GGO; reticular opacity, RO; honeycombing, HC; emphysema, EMPH; and consolidation, CONS, was developed using texture and shape features. Fifty-four patients with pathologically proven UIP (n = 26) and pathologically proven NSIP (n = 28) were included as part of this study. Inter-observer agreement in measuring the extent of each HRCT pattern between the system and two thoracic radiologists were assessed in 26 randomly selected subsets using an interclass correlation coefficient (ICC). A linear regression analysis was used to assess the contribution of each disease pattern to the pulmonary function test parameters. The discriminating capacity of the system between UIP and NSIP was evaluated using a binomial logistic regression. RESULTS: The overall ICC showed acceptable agreement among the system and the two radiologists (r = 0.895 for the abnormal lung volume fraction, 0.706 for the fibrosis fraction, 0.895 for NL, 0.625 for GGO, 0.626 for RO, 0.893 for HC, 0.800 for EMPH, and 0.430 for CONS). The volumes of NL, GGO, RO, and EMPH contribute to forced expiratory volume during one second (FEV1) (r = 0.72, beta values, 0.84, 0.34, 0.34 and 0.24, respectively) and forced vital capacity (FVC) (r = 0.76, beta values, 0.82, 0.28, 0.21 and 0.34, respectively). For diffusing capacity (DLco), the volumes of NL and HC were independent contributors in opposite directions (r = 0.65, beta values, 0.64, -0.21, respectively). The automated system can help discriminate between UIP and NSIP with an accuracy of 82%. CONCLUSION: The automated quantification system of regional HRCT patterns can be useful in the assessment of disease severity and may provide reliable agreement with the radiologists' results. In addition, this system may be useful in differentiating between UIP and NSIP.

Evidence-based National Vaccine Policy.

India has over a century old tradition of development and production of vaccines. The Government rightly adopted self-sufficiency in vaccine production and self-reliance in vaccine technology as its policy objectives in 1986. However, in the absence of a full-fledged vaccine policy, there have been concerns related to demand and supply, manufacture vs. import, role of public and private sectors, choice of vaccines, new and combination vaccines, universal vs. selective vaccination, routine immunization vs. special drives, cost-benefit aspects, regulatory issues, logistics etc. The need for a comprehensive and evidence based vaccine policy that enables informed decisions on all these aspects from the public health point of view brought together doctors, scientists, policy analysts, lawyers and civil society representatives to formulate this policy paper for the consideration of the Government. This paper evolved out of the first ever ICMR-NISTADS national brainstorming workshop on vaccine policy held during 4-5 June, 2009 in New Delhi, and subsequent discussions over email for several weeks, before being adopted unanimously in the present form.

Biopsia en enfermedad intersticial pulmonar / Lung biopsy for the diagnosis of interstitial lung disease

El objetivo del presente estudio fue determinar el rédito diagnóstico y los factores asociados a mayor morbimortalidad en la biopsia quirúrgica de pulmón en pacientes con enfermedad intersticial difusa. Se analizaron en forma retrospectiva los registros clínicos de 71 pacientes. Se registraron complicaciones en 16 pacientes (22.5%). La mortalidad operatoria fue 11.2%. Los pacientes en quienes la biopsia se realizó por videotoracoscopia (n = 52) y por toracotomía (n = 17) tuvieron la misma duración de estadía en terapia intensiva y de estadía hospitalaria. La tasa de complicaciones (22.2% vs. 21.0%, p = 1.0000) y la mortalidad (9.2 vs. 15.7%, p = 0.2738) no fueron diferentes. Ocho pacientes murieron dentro de los 30 días. La prevalencia de inmunosupresión (4/8 vs. 9/63, p = 0.0325) fue significativamente superior en el grupo de pacientes fallecidos. Estos pacientes tuvieron valores preoperatorios más elevados de urea (50 ± 20.1 mg/dl vs. 31.2 ± 10.3 mg/ dl, p = 0.0013) y menores valores de saturación de O2: 82.7 ± 14.8% vs. 92.8 ± 3.4%, p = 0.0009. En los 11 pacientes con iniciación aguda la mortalidad fue significativamente más elevada (36.3% vs. 7.1%, p = 0.0223). La biopsia aportó un diagnóstico específico en 100% de los pacientes y cambió la estrategia terapéutica en 66.7%. En conclusión, la biopsia de pulmón por vía toracoscópica es un procedimiento útil y seguro en los pacientes con enfermedad intersticial difusa del pulmón. Sin embargo, en el grupo de pacientes inmunocomprometidos, con cuadros de presentación aguda y con insuficiencia respiratoria preoperatoria, la mortalidad es elevada y deben balancearse muy críticamente los riesgos contra los beneficios en ese grupo de enfermos.

The objective of this study was to determine the morbidity, mortality and diagnostic yield of video assisted thoracoscopy (VATS) and thoracotomy lung biopsy in interstitial lung disease (ILD). Clinical records of 71 patients were retrospectively analyzed. There was no difference in mean hospital stay, intensive care unit stay and duration of chest tube drainage in patients with VATS (n = 52) compared with those undergoing open thoracotomy (n = 17). Complications rate (22.2% vs. 21.0%, p = 1.0000) and operating mortality (9.2 vs. 15.7%, p = 0.2738) were also similar. Overall, complications occurred in 16 patients (22.5%). Thirty-day mortality rate was 11.2% (n = 8). Prevalence of immunosupression (4/8 vs. 9/63, p = 0.0325) was significantly higher in the group of patients who died. No surviving patients had higher values of plasmatic urea (50 ± 20.1 mg/dl vs. 31.2 ± 10.3 mg/dl, p = 0.0013) or lower values of preoperative oxygen saturation (SaO2): 82.7 ± 14.8% vs. 92.8 ± 3.4%, (p = 0.0009). Eleven patients had an acute illness. Those patients did not show a higher complication rate (4/11 vs. 10/45, p = 0.4390) but mortality was significantly higher (4/11, 36.3% vs. 3/45, 7.1%, p = 0.0223). Biopsy allowed a specific histologic diagnosis in 100% of patients and changed therapy in 66.7%. We conclude that surgical lung biopsy is a safe and useful procedure in patients with ILD. However the higher mortality rate in patients with acute symptoms, immunocompromise, or in respiratory failure must be balanced against potential benefits of altering treatment decisions.

The Prognostic Value of Fibroblastic Foci Quantity in Patenets with Usual Interstitial Pneumonia / 결핵

BACKGROUND: Usual interstitial pneumonia (UIP) is a progressive fibrous lung disease with occasional fatal outcomes. However, the extent and rate of progression varies markedly from one patient to another. As a result, it is difficult to determine the time of the initial treatment and assess the disease activity and course. Fibroblast foci (FF) is well known to synthesize collagen actively by their myofibroblasts component. However, the prognostic value of the FF have not been evaluated in patients with UIP. Therefore this study was undertaken to determine how the number of fibroblastic foci can reflect the disease activity and progression. METHODS: Twenty patients with UIP(M:F=13:7), who were diagnosed by a surgical lung biopsy. The number of fibroblastic foci was analyzed in terms of its correlation with the clinical manifestations. pulmonary function test, arterial blood gas analysis, and a bronchoalveolar lavage(BAL). RESULTS: The number of fibroblastic foci did not correlate with the various lung function tests and the other clinical parameters. Intersetingly, the percentage of neutrophils in the bronchoalveolar lavage fluid did correlate with the quantity of the normalized Vv of FF(r=0.60, p<0.05). The patients were divided into 2 groups, group I and II, arbitratily, according to the value of the normalized Vv. The clinical parameters and the PFT results were not different between the two groups. In particular, the survival rate between the two groups according to the Kaplan-Meier analysis were not different. CONCLUSION: A large number of FF does not imply a bad prognosis in patients wit UIP.

The Activity of c-Jun N-terminal Kinase (JNKb) in Patients with UIP / 결핵

BACKGROUND: TNF-alpha is related to the generation of lung fibrosis in patients with UIP. The precise mechanism leading to lung fibrosis by TNF-alpha is unknown. However, the activation of a transcription factor like AP-1(down stream of c-jun N-terminal kinase, JNK) by TNF-alpha may be related to the induction of fibrogenic cytokines like PDGF or IGF-I. Furthermore, JNK was reported to be activated in the radiation-in-duced lung fibrosis model. This study examined JNK activity in patients with UIP. METHODS: The expression of phosphorous JNK(p-JNK), macrophage/moncoyte specific markers, CD68, and cytokeratin was evaluated by immunohistochemical (IHC) staining of lung tissues from patients with UIP and lung cancer. An in vitro kinase assay was performed with alveolar macrophages obtained by a bronchollung cancer. An in vitro kinase assay was performed with alvolar macrophages obrtained by a bronchol avleolar lavage from patients with UIP and healthy persons as the control. RESULTS: The IHC stain showed that p-JNK is expressed in the almost all of the alveolar macrophages and smooth muscle cells in patients with UIP. In case of the normal areas of the lung from patients with lung cancer, the alveolar macrophages showed little p-JNK expression. Interestingly, increased JNK activity was not found in the in vitro kinase assay of the alveolar macrophages obtained from both patients with UIP and healthy persons as the control. Furthermore, 10 ng/ml of TNF-alpha failed to increase the JNK activity of the alveolar macrophages in both patients with UIP and healthy people. CONCLUSION: The JNK was activated constitutionally in patients with UIP. However, the role of JNK in the pathogenesis of lung fibrosis needs to be clarified.

Clinical Course of Usual Interstitial Pneumonia / 결핵

BACKGROUND: Idiopathic pulmonary fibrosis(IPF) is a fatal progressive fibrous disease of the lung of unknown etiology. Recently it has been classified into several distinct entities of the basis of pathologic and clinical characteristics, ie : usual interstitial pneumonia(UIP), desquamative interstitial pneumonia(DIP), acute interstitial pneumonia(AIP), bronchiolitis obliterans with organizing pneumonia(BOOP), and nonspecific interstitial pneumonia(NSIP). IPF is now applied only for UIP, which has the worst prognosis. The previous reports of 3-5 year median survival apears to be overoptimistic because other types with better prognosis like NSIP or BOOP might have been included. Therefore, this study was performed to determine the clinical course and the prognostic factors of UIP as diagnosed by surgical lung biopsy. METHODS: The subjects were 72 UIP patients (age 58.2±11.6 years, M:F=45:27, median follow up period:18.1 months (0.7-103.6) diagnosed by surgical lung biopsy at the Asan Medical Center (68 patients) and the Paik Hospital in Seoul (4 patients). Clinical scores (level of dyspnea:1-20 points), radiologic score (honey-combing : HC score 0-5 points, ground glass : GG score 0-5 points), and physiologic scores (FVC:1-12 points, FEV1:0-3 points, TLC:0-10 points, DDLC:0-5 points, AaDO2:0-10 points) were summed into a total CRP score. RESULTS: 1) The one year survival rate was 78.3%, while the rate for three year survival was 58.1%, and the median survival period was 42.5 months. 2) Short term (1 year) prognosis : The patients who died within one year of diagnosis (14 patients) had the higher initial total CRP score (28.6±8.3 vs. 16.6±9.7) than those who lived longer than one year (46 patients). The difference in the total CRP score was attributed to the symptom score (8.4±2.1 vs. 5.7±3.9) and the physiologic score (15.7±7.1 vs. 6.7±5.7) including FVC, DLCO, and AaDO2. 3) Long-term (3 year) prognosis : The total CRP score (12.2±6.7 vs. 28.7±7.9:including symptom score, FVC, DLCO, and AaDO2) at the time of diagnosis were also different for the long-term survivors and those who lived less than 3 years. 4) Cox regression analysis showed LCO (≥60%) (Hazard ratio:4.56, 95% CI:2.30-16.04) was the independent prognostic factors of UIP (P<0.05). CONCLUSION: These results suggest that DLCO at the time of diagnosis seem to be a prognostic markers of biopsy-proven UIP.

Clinical differential diagnosis of usual interstitial pneumonia from nonspecific interstitial pneumonia / 결핵

BACKGROUND: Nonspecific interstitial pneumonitis (NSIP) is most likely to be confused with usual interstitial pneumonitis (UIP). Unlike patients with UIP, the majority of patients with NSIP have a good prognosis, with most patients improving after treatment with corticosteroids. Therefore it is clinically important to differentiate NSIP from UIP. UP to now, the only means of differentiating these two diseases was by means of surgical lung biopsy. American Thoracic Society (ATS) proposed a clinical diagnostic criterial for UIP to provide assistance to clinicians in its diagnosis without surgical lung biopsy. This study is aimed to investigate whether there were clinical and radiological differences between NSIP and UIP, and the usefulness of ATS clinical diagnostic criteria for UIP in Korea. METHODS: we studied 60 patients with UIP and NSIP confirmed by surgical lung biopsy. Clinical manifestations, pulmonary function test, arterial blood gas analysis, bronchoalveolar lavage (BAL), and high resolution computed tomography (HRCT) were evaluated and analyzed by Chi-square test or t-test. The clinical criteria for UIP proposed by ATS were applied to all patients with idiopathic interstitial pneumonia. RESULTS: Forty-two patients with UIP and 18 with NSIP were pathologically identified. Among the 18 patients with NSIP (M : F = 1 : 17), the mean age was 55.2± 8.4 (44~73)yr. Among the 42 patients with UIP (M : F = 33 : 9), the mean age was 59.5±7.1 (45~74) yr (p=0.0460. Fever was more frequent in NSIP (39%) (p=0.034), but clubbing was frequently observed in UIP (33%) (p=0.023). BAL lymphocytosis was more frequent (23%) (p=0.0001) and CD4/CD8 ratio was lower in NSIP (p=0.045). On HRCT, UIP frequently showed honeycomb appearance (36 of 42 patients) through not in NSIP (p=0.0001). Six of 42 UIP patients (14.3%) met the ATS clinical criteria for IPF, and 3 of 16 NSIP patients (18.8%) met the diagnostic criteria. CONCLUSION: Being a relatively young female and having short duration of illness, fever, BAL lymphocytosis, low CD4/CD8 ratio with the absence of clubbing and honeycomb appearance in HRCT increase the likelihood of the illness being NSIP. The usefulness of ATS clinical diagnostic criteria for UIP may be low in Korea.