The WHO Tailoring Immunization Programmes (TIP) approach: Review of implementation to date.

INTRODUCTION: The WHO Regional Office for Europe developed the Guide to tailoring immunization programmes (TIP), offering countries a process through which to diagnose barriers and motivators to vaccination in susceptible low vaccination coverage and design tailored interventions. A review of TIP implementation was conducted in the European Region. MATERIAL AND METHODS: The review was conducted during June to December 2016 by an external review committee and was based on visits in Bulgaria, Lithuania, Sweden and the United Kingdom that had conducted a TIP project; review of national and regional TIP documents and an online survey of the Member States in the WHO European Region that had not conducted a TIP project. A review committee workshop was held to formulate conclusions and recommendations. RESULTS: The review found the most commonly cited strengths of the TIP approach to be the social science research as well as the interdisciplinary approach and community engagement, enhancing the ability of programmes to "listen" and learn, to gain an understanding of community and individual perspectives. National immunization managers in the Region are generally aware that TIP exists and that there is strong demand for the type of research it addresses. Further work is needed to assist countries move towards implementable strategies based on the TIP findings, supported by an emphasis on enhanced local ownership; integrated diagnostic and intervention design; and follow-up meetings, advocacy and incentives for decision-makers to implement and invest in strategies. CONCLUSIONS: Understanding the perspectives of susceptible and low-coverage populations is crucial to improving immunization programmes. TIP provides a framework that facilitated this in four countries. In the future, the purpose of TIP should go beyond identification of susceptible groups and diagnosis of challenges and ensure a stronger focus on the design of strategies and appropriate and effective interventions to ensure long-term change.

Tuberculosis Elimination Efforts in the United States in the Era of Insurance Expansion and the Affordable Care Act.

The Patient Protection and Affordable Care Act can enhance ongoing efforts to control tuberculosis (TB) in the United States by bringing millions of currently uninsured Americans into the health-care system. However, much of the legislative and financial framework that provides essential public health services necessary for effective TB control is outside the scope of the law. We identified three key issues that will still need to be addressed after full implementation of the Affordable Care Act: (1) essential TB-related public health functions will still be needed and will remain the responsibility of federal, state, and local health departments; (2) testing and treatment for latent TB infection (LTBI) is not covered explicitly as a recommended preventive service without cost sharing or copayment; and (3) remaining uninsured populations will disproportionately include groups at high risk for TB. To improve and continue TB control efforts, it is important that all populations at risk be tested and treated for LTBI and TB; that testing and treatment services be accessible and affordable; that essential federal, state, and local public health functions be maintained; that private-sector medical/public health linkages for diagnosis and treatment be developed; and that health-care providers be trained in conducting appropriate LTBI and TB clinical care.

Health risks, travel preparation, and illness among public health professionals during international travel.

BACKGROUND: Few data currently exist on health risks faced by public health professionals (PHP) during international travel. We conducted pre- and post-travel health surveys to assess knowledge, attitudes, and practices (KAP), and illnesses among PHP international travelers. METHOD: Anonymous surveys were completed by PHP from a large American public health agency who sought a pre-travel medical consult from September 1, 2009, to September 30, 2010. RESULTS: Surveys were completed by 122 participants; travelers went to 163 countries. Of the 122 respondents, 97 (80%) reported at least one planned health risk activity (visiting rural areas, handling animals, contact with blood or body fluids, visiting malarious areas), and 50 (41%) reported exposure to unanticipated health risks. Of the 62 travelers who visited malarious areas, 14 (23%) reported inconsistent or no use of malaria prophylaxis. Illness during travel was reported by 33 (27%) respondents. CONCLUSIONS: Most of the PHP travelers in our study reported at least one planned health risk activity, and almost half reported exposure to unanticipated health risks, and one-quarter of travelers to malarious areas reported inconsistent or no use of malaria chemoprophylaxis. Our findings highlight that communication and education outreach for PHP to prevent travel-associated illnesses can be improved.

Diarrheal illness among US residents providing medical services in Haiti during the cholera epidemic, 2010 to 2011.

Although nosocomial transmission of cholera is rare, two US healthcare workers (HCW) became ill with cholera after providing medical services during the Haiti cholera epidemic. To assess the incidence of diarrheal illness and explore preventive health behaviors practiced by US residents who provided medical services in Haiti, we conducted a cross-sectional, anonymous, web-based survey. We e-mailed 896 participants from 50 US-based, health-focused non-governmental organizations (NGOs), of whom 381 (43%) completed the survey. Fifty-six percent of respondents (n = 215) reported providing some care for patients with cholera. Diarrhea was reported by 31 (8%) respondents. One person was diagnosed with cholera by serologic testing. NGOs responding to international emergencies should ensure ample access to basic hygiene supplies and should promote their use to reduce the incidence of diarrheal illness among HCW working overseas.

Protective practices and respiratory illness among US travelers to the 2009 Hajj.

BACKGROUND: All mass gatherings can place travelers at risk for infectious diseases, but the size and density of the annual Hajj pilgrimage to the Kingdom of Saudi Arabia (KSA) present important public health and infection control challenges. This survey of protective practices and respiratory illness among US travelers to the 2009 Hajj was designed to evaluate whether recommended behavioral interventions (hand hygiene, wearing a face mask, cough etiquette, social distancing, and contact avoidance) were effective at mitigating illness among travelers during the 2009 Hajj. METHODS: US residents from Minnesota and Michigan completed anonymous surveys prior to and following travel to the 2009 Hajj. Surveys assessed demographics, knowledge, attitudes, and practices (KAP) related to influenza A(H1N1), vaccination, health-seeking behaviors, sources of health information, protective behaviors during the Hajj, and respiratory illness during and immediately after the Hajj. RESULTS: Pre- and post-travel surveys were completed by 186 participants. Respiratory illness was reported by 76 (41.3%) respondents; 144 (77.4%) reported engaging in recommended protective behaviors during the Hajj. Reduced risk of respiratory illness was associated with practicing social distancing, hand hygiene, and contact avoidance. Pilgrims who reported practicing more recommended protective measures during the Hajj reported either less occurrence or shorter duration of respiratory illness. Noticing influenza A(H1N1) health messages during the Hajj was associated with more protective measures and with shorter duration of respiratory illness. CONCLUSIONS: Recommended protective behaviors were associated with less respiratory illness among US travelers to the 2009 Hajj. Influenza A(H1N1) communication and education in KSA during the Hajj may also have been an effective component of efforts to mitigate illness. Evaluations of communication efforts and preventive measures are important in developing evidence-based public health plans to prevent and mitigate disease outbreaks at the Hajj and other mass gatherings.

Knowledge, attitudes, and practices of US travelers to Asia regarding seasonal influenza and H5N1 avian influenza prevention measures.

BACKGROUND: International travel is a potential risk factor for the spread of influenza. In the United States, approximately 5%-20% of the population develops an influenza-like illness annually. The purpose of this study was to describe the knowledge, attitude, and practices of US travelers to Asia regarding seasonal influenza and H5N1 avian influenza (AI) prevention measures. METHODS: We surveyed travelers to Asia waiting at the departure lounges of 38 selected flights at four international airports in New York, Chicago, Los Angeles, and San Francisco. Of the 1,301 travelers who completed the pre-travel survey, 337 also completed a post-travel survey. Univariate and multivariate logistic regression were used to calculate prevalence odds ratios (with 95% CI) to compare foreign-born (FB) to US-born travelers for various levels of knowledge and behaviors. RESULTS: Although the majority of participants were aware of influenza prevention measures, only 41% reported receiving the influenza vaccine during the previous season. Forty-three percent of participants reported seeking at least one type of pre-travel health advice, which was significantly higher among US-born, Caucasians, traveling for purposes other than visiting friends and relatives, travelers who received the influenza vaccine during the previous season, and those traveling with a companion. Our study also showed that Asians, FB travelers, and those working in occupations other than health care/animal care were less likely to recognize H5N1 AI transmission risk factors. CONCLUSION: The basic public health messages for preventing influenza appear to be well understood, but the uptake of influenza vaccine was low. Clinicians should ensure that all patients receive influenza vaccine prior to travel. Tailored communication messages should be developed to motivate Asians, FB travelers, those visiting friends and relatives, and those traveling alone to seek pre-travel health advice as well as to orient them with H5N1 AI risk factors.

Travel characteristics and risk-taking attitudes in youths traveling to nonindustrialized countries.

BACKGROUND: International travel to developing countries is increasing with rising levels of disposable income; this trend is seen in both adults and children. Risk-taking attitude is fundamental to research on the prevention of risky health behaviors, which can be an indicator of the likelihood of experiencing illness or injury during travel. The aim of this study is to investigate whether risk-taking attitudes of youths are associated with travel characteristics and likelihood of experiencing illness or injury while traveling to nonindustrialized countries. METHODS: Data were analyzed from the 2008 YouthStyles survey, an annual mail survey gathering demographics and health knowledge, attitudes, and practices of individuals from 9 through 18 years of age. Travelers were defined as respondents who reported traveling in the last 12 months to a destination other than the United States, Canada, Europe, Japan, Australia, or New Zealand. Risk-taking attitude was measured by using a four-item Brief Sensation-Seeking Scale. All p values ≤ 0.05 were considered significant. RESULTS: Of 1,704 respondents, 131 (7.7%) traveled in the last 12 months. Females and those with higher household income were more likely to travel (odds ratio = 1.6,1.1). Of those who traveled, 16.7% reported seeking pretravel medical care, with most visiting a family doctor for that care (84.0%). However, one-fifth of respondents reported illness and injury during travel; of these, 83.3% traveled with their parents. Males and older youths had higher mean sensation-seeking scores. Further, travelers had a higher mean sensation-seeking score than nontravelers. Those who did not seek pretravel medical care also had higher mean sensation-seeking scores (p = 0.1, not significant). CONCLUSIONS: Our results show an association between risk-taking attitudes and youth travel behavior. However, adult supervision during travel and parental directives prior to travel should be taken into consideration. Communication messages should emphasize the importance of pretravel advice, target parents of children who are traveling, and be communicated through family doctors.

Health risks and travel preparation among foreign visitors and expatriates during the 2008 Beijing Olympic and Paralympic Games.

During the 2008 Olympic and Paralympic Games, we conducted surveillance of illnesses among travelers at six Beijing clinics. Surveys asked about demographic, pre-travel, and vaccination information, and physician-provided diagnoses. Of 807 respondents, 38% and 57% were classified as foreign visitors (FV) and expatriates, respectively. Less than one-half of FV sought pre-travel advice; sources included health-care providers and friends/family. FV vaccination rate was also low; however, most vaccines given were recommended by the Centers for Disease Control and Prevention. The most common FV diagnoses were respiratory, injury/musculoskeletal, and gastrointestinal illnesses; for expatriates, injury/musculoskeletal, respiratory, and dermatologic were the most common illnesses. Respiratory illnesses in expatriates were significantly less in 2008 than during 2004-2007 (chi(2) = 10.2; P = 0.0014), suggesting that control programs may have reduced pollutants/respiratory irritants during the 2008 Games. We found no previous studies of health outcomes among expatriates living in cities with mass travel events. These findings highlight the need to continuously disseminate information to health-care providers advising travelers.

Psychological assessment of children in disasters and emergencies.

Children and adolescents are among the most vulnerable members of communities affected by disasters and emergencies. There is a tremendous need for a systematic post-disaster psychological assessment of children and adolescents in order to understand better post-traumatic symptomatology in children and to identify populations that require an early intervention. This article reviews psychological instruments that are suitable for screening children and adolescents in emergency and disaster contexts for four different types of post-traumatic responses: post-traumatic stress disorder; depression; anxiety disorders; and behavioural disorders. A description of each instrument and psychometric data are provided, along with recommendations on the most appropriate instruments to be utilised in different emergency environments and a summary of previous post-disaster evaluations that have used each type. In addition to selecting apposite instruments, other important issues that should be taken into account when conducting post-emergency mental health needs appraisals of children and adolescents are discussed.

Posttraumatic stress in children with first responders in their families.

High levels of exposure and occupational stress of first responders may have caused children in first-responder families to become traumatized following the September 11th, 2001 terrorist attacks. New York City public school children (N = 8,236) participated in a study examining mental health problems 6 months after the World Trade Center attack. Results revealed that children with emergency medical technician (EMT) family members had a high prevalence of probable posttraumatic stress disorder (PTSD; 18.9%). Differences in rates of probable PTSD among EMTs' and firefighters' children were explained by demographic characteristics. Where EMTs are drawn from disadvantaged groups, one implication of this study is to target EMT families in any mental health interventions for children of first responders.

Psychopathology among New York city public school children 6 months after September 11.

CONTEXT: Children exposed to a traumatic event may be at higher risk for developing mental disorders. The prevalence of child psychopathology, however, has not been assessed in a population-based sample exposed to different levels of mass trauma or across a range of disorders. OBJECTIVE: To determine prevalence and correlates of probable mental disorders among New York City, NY, public school students 6 months following the September 11, 2001, World Trade Center attack. DESIGN: Survey. SETTING: New York City public schools. PARTICIPANTS: A citywide, random, representative sample of 8236 students in grades 4 through 12, including oversampling in closest proximity to the World Trade Center site (ground zero) and other high-risk areas. MAIN OUTCOME MEASURE: Children were screened for probable mental disorders with the Diagnostic Interview Schedule for Children Predictive Scales. RESULTS: One or more of 6 probable anxiety/depressive disorders were identified in 28.6% of all children. The most prevalent were probable agoraphobia (14.8%), probable separation anxiety (12.3%), and probable posttraumatic stress disorder (10.6%). Higher levels of exposure correspond to higher prevalence for all probable anxiety/depressive disorders. Girls and children in grades 4 and 5 were the most affected. In logistic regression analyses, child's exposure (adjusted odds ratio, 1.62), exposure of a child's family member (adjusted odds ratio, 1.80), and the child's prior trauma (adjusted odds ratio, 2.01) were related to increased likelihood of probable anxiety/depressive disorders. Results were adjusted for different types of exposure, sociodemographic characteristics, and child mental health service use. CONCLUSIONS: A high proportion of New York City public school children had a probable mental disorder 6 months after September 11, 2001. The data suggest that there is a relationship between level of exposure to trauma and likelihood of child anxiety/depressive disorders in the community. The results support the need to apply wide-area epidemiological approaches to mental health assessment after any large-scale disaster.

Impact of 2003 power outages on public health and emergency response.

INTRODUCTION: In 2003, a major power outage occurred in the midwest and northeast United States affecting some 50 million people. The power outages affected multiple systems in state and local municipalities and, in turn, affected public health. METHODS: Semi-structured interviews were conducted using open-ended questionnaires, with a convenience sample of state- and locally selected subject matter experts from Ohio, Michigan, and New York. Respondents were interviewed in groups representing one of five areas of interest, including: (1) emergency preparedness; (2) hospital and emergency medical services; (3) municipal environmental systems; (4) public health surveillance and epidemiology; and (5) psychosocial and behavioral issues. The reported positive and negative impacts of the power outage on public health, medical services, and emergency preparedness and response were documented. Responses were categorized into common themes and recommendations were formulated. RESULTS: The amount of time that the respondents' locations were without power ranged from <1 hour to 52 hours. Many common themes emerged from the different locations, including communications failures, alternate power source problems, manpower and training issues, and psychosocial concerns. There was minimal morbidity and mortality reported that could be attributed to the event. CONCLUSION: Power outages negatively impacted multiple municipal infra-structures, and affected medical services, emergency response, and public health efforts. Previous federal funding positively impacted public health and emergency response capabilities. Recommendations were made based upon the common themes identified by the respondents. Recommendations may assist state and local health departments, medical service providers, and emergency responders in planning for future power outage problems.