Timeliness of Childhood Vaccinations Following Strengthening of the Second Year of Life (2YL) Immunization Platform and Introduction of Catch-Up Vaccination Policy in Ghana.

Strengthening routine immunization systems to successfully deliver childhood vaccines during the second year of life (2YL) is critical for vaccine-preventable disease control. In Ghana, the 18-month visit provides opportunities to deliver the second dose of the measles-rubella vaccine (MR2) and for healthcare workers to assess for and provide children with any missed vaccine doses. In 2016, the Ghana Health Service (GHS) revised its national immunization policies to include guidelines for catch-up vaccinations. This study assessed the change in the timely receipt of vaccinations per Ghana's Expanded Program on Immunizations (EPI) schedule, an important indicator of service quality, following the introduction of the catch-up policy and implementation of a multifaceted intervention package. Vaccination coverage was assessed from household surveys conducted in the Greater Accra, Northern, and Volta regions for 392 and 931 children aged 24-35 months with documented immunization history in 2016 and 2020, respectively. Age at receipt of childhood vaccines was compared to the recommended age, as per the EPI schedule. Cumulative days under-vaccinated during the first 24 months of life for each recommended dose were assessed. Multivariable Cox regression was used to assess the associations between child and caregiver characteristics and time to MR2 vaccination. From 2016 to 2020, the proportion of children receiving all recommended doses on schedule generally improved, the duration of under-vaccination was shortened for most doses, and higher coverage rates were achieved at earlier ages for the MR series. More timely infant doses and caregiver awareness of the 2YL visit were positively associated with MR2 vaccination. Fostering a well-supported cadre of vaccinators, building community demand for 2YL vaccination, sustaining service utilization through strengthened defaulter tracking and caregiver-reminder systems, and creating a favorable policy environment that promotes vaccination over the life course are critical to improving the timeliness of childhood vaccinations.

Clinical Characteristics of Neurocysticercosis in a Peruvian Population-Based Epilepsy Cohort: A Descriptive Cross-Sectional Study of Baseline Clinical Intake.

(1) Background: This study presents the baseline characteristics of a community-level population of people with epilepsy (n = 1975) living in an area endemic for Taenia solium, the pathogen responsible for neurocysticercosis (NCC). (2) Methods: Participants were sequentially enrolled in a clinical cohort from 2007 to 2020 in Tumbes, Peru. All participants provided demographic and clinical history and received clinical evaluations. Diagnostics, including neuroimaging, cysticercosis serologies, and EEG, were obtained where possible. The data presented are from the cross-sectional baseline assessment of cohort participants. (3) Results: Approximately 38% of participants met the criteria for NCC. Those with NCC were more likely to have adult-onset epilepsy, as well as a longer duration of epilepsy, as compared to their counterparts without NCC. Overall, the data indicate a large treatment gap, with only approximately a quarter of the baseline population with prescriptions for anti-seizure medications. (4) Conclusions: These data reveal a high proportion of NCC among people living with epilepsy in these communities, with limited health care resources. At baseline, 74% of the population were not receiving anti-seizure treatments. Further analyses of these data will clarify the natural history of the disease for this population.

Predictors for Uptake of Vaccines Offered during the Second Year of Life: Second Dose of Measles-Containing Vaccine and Meningococcal Serogroup A-Containing Vaccine, Ghana, 2020.

BACKGROUND: Understanding the drivers of coverage for vaccines offered in the second year of life (2YL) is a critical focus area for Ghana's life course approach to vaccination. This study characterizes the predictors of vaccine receipt for 2YL vaccines-meningococcal serogroup A conjugate vaccine (MACV) and the second dose of measles-containing vaccine (MCV2)-in Ghana. METHODS: 1522 children aged 18-35 months were randomly sampled through household surveys in the Greater Accra Region (GAR), Northern Region (NR), and Volta Region (VR). The association between predictors and vaccination status was modeled using logistic regression with backwards elimination procedures. Predictors included child, caregiver, and household characteristics. RESULTS: Coverage was high for infant vaccines (>85%) but lower for 2YL vaccines (ranging from 60.2% for MACV in GAR to 82.8% for MCV2 in VR). Predictors of vaccination status varied by region. Generally, older, first-born children, those living in rural settlements and those who received their recommended infant vaccines by their first birthday were the most likely to have received 2YL vaccines. Uptake was higher among those with older mothers and children whose caregivers were aware of the vaccination schedule. CONCLUSIONS: Improving infant immunization uptake through increased community awareness and targeted strategies, such as parental reminders about vaccination visits, may improve 2YL vaccination coverage.

Development and Laboratory Evaluation of a Simple, Field-Applicable Coproantigen Enzyme-Linked Immunosorbent Assay for Diagnosis of Taeniasis in Northern Peru.

Coproantigen detection by enzyme-linked immunosorbent assay (coAg ELISA) is a vital tool for detecting and treating cases of Taenia solium taeniasis. However, the assay's procedures require costly materials and sophisticated equipment, which are typically inaccessible in rural settings where the disease is endemic. To overcome these barriers, we developed and evaluated a field-applicable coAg ELISA. The field coAg ELISA was developed and evaluated across four phases using known positive and negative stool samples collected from northern Peru. Phase I focused on field assay development, phase II on a small-scale performance evaluation, phase III on a large-scale evaluation, and phase IV on the use and reliability of a colorimetric scale card. All samples were processed using the field and standard assay procedures and compared using signal-to-noise ratios, correlation tests, performance characteristics, and agreement statistics where appropriate. The field coAg ELISA using reagents stored at -20°C and commercially available water and milk powder, and relying on spontaneous separation of the supernatant, had performance comparable to the standard assay. The field coAg ELISA was strongly correlated with the standard in both the small- and large-scale laboratory evaluation (r = 0.99 and r = 0.98, respectively). Finally, the field assay had an almost perfect agreement between independent readers (kappa = 0.975) and between each reader and the spectrophotometer. The field coAg ELISA demonstrated performance comparable to the standard, providing a low-cost alternative to the standard assay for identifying cases of intestinal taeniasis in a low-resource setting.

Evaluation of Container Clinics as an Urban Immunization Strategy: Findings from the First Year of Implementation in Ghana, 2017-2018.

BACKGROUND: In 2017, the Expanded Programme on Immunization in Ghana opened two container clinics in Accra, which were cargo containers outfitted to deliver immunizations. At each clinic, we assessed performance and clinic acceptance during the first 12 months of implementation. METHODS: We employed a descriptive mixed-method design using monthly administrative immunization data, exit interviews with caregivers of children of <5 years (N = 107), focus group discussions (FGDs) with caregivers (n = 6 FGDs) and nurses (n = 2 FGDs), and in-depth interviews (IDIs) with community leaders (n = 3) and health authorities (n = 3). RESULTS: Monthly administrative data showed that administered vaccine doses increased from 94 during the opening month to 376 in the 12th month across both clinics. Each clinic exceeded its target doses for the 12-23 month population (second dose of measles). Almost all (98%) exit interview participants stated that the clinics made it easier to receive child health services compared to previous health service interactions. The accessibility and acceptability of the container clinics were also supported from health worker and community perspectives. CONCLUSIONS: Our initial data support container clinics as an acceptable strategy for delivering immunization services in urban populations, at least in the short term. They can be rapidly deployed and designed to serve working mothers in strategic areas.

Applying Adult Learning Best Practices to Design Immunization Training for Health Care Workers in Ghana.

INTRODUCTION: A 2016 assessment of frontline health care workers (HCWs) in Ghana identified knowledge, skill, and attitude gaps related to immunization during the second year of life (2YL). The U.S. Centers for Disease Control and Prevention subsequently supported the Ghana Health Service Immunization Program to apply best practices of adult learning and training of trainers (TOT) for a cascade training program for 2YL. METHODS: Five districts from each of the 3 regions (Greater Accra, Northern, and Volta) were selected for the TOT based on key measles and rubella vaccination coverage indicators. The design incorporated best practices of adult learning and TOT. The curriculum integrated 3 major topical themes: technical (immunization topics), operational, and training adults. The technical and operational content was based on HCW tasks most directly affecting 2YL objectives. A cross-functional team developed all classroom, field activity, and training evaluation materials. RESULTS: Seventy-four participants attended TOT workshops in 2017. Based on a rubric defined by the course designers, 99% of the participants reported an acceptable level of confidence to apply and teach the course content. After the TOTs, participants conducted 65 workshops, 43 field visits, and 4 review meetings, reaching 1,378 HCWs within 7 months. Fifty-four percent of HCWs who received training from TOT participants reported an acceptable level of confidence in using the skills, and 92% reported they would prioritize applying the skills acquired during the training. DISCUSSION: The success factors for effective adult learning and TOT can be applied to design and implement high-quality TOT even in resource-limited settings. The factors include using a variety of approaches, spending enough class time to prepare TOT participants for their training role, setting specific expectations for cascading the training, and following up through mentorship and reporting. Strong collaboration across the administrative levels of the Ghana Health Service enabled cascade training.

Building health workforce capacity for planning and monitoring through the Strengthening Technical Assistance for routine immunization training (START) approach in Uganda.

INTRODUCTION: The Global Vaccine Action Plan identifies workforce capacity building as a key strategy to achieve strong immunization programs. The Strengthening Technical Assistance for Routine Immunization Training (START) approach aimed to utilize practical training methods to build capacity of district and health center staff to implement routine immunization (RI) planning and monitoring activities, as well as build supportive supervision skills of district staff. METHODS: First implemented in Uganda, the START approach was executed by trained external consultants who used existing tools, resources, and experiences to mentor district-level counterparts and, with them, conducted on-the-job training and mentorship of health center staff over several site visits. Implementation was routinely monitored using daily activity reports, pre and post surveys of resources and systems at districts and health centers and interviews with START consultants. RESULTS: From July 2013 through December 2014 three START teams of four consultants per team, worked 6 months each across 50 districts in Uganda including the five divisions of Kampala district (45% of all districts). They conducted on-the-job training in 444 selected under-performing health centers, with a median of two visits to each (range 1-7, IQR: 1-3). More than half of these visits were conducted in collaboration with the district immunization officer, providing the opportunity for mentorship of district immunization officers. Changes in staff motivation and awareness of challenges; availability and completion of RI planning and monitoring tools and systems were observed. However, the START consultants felt that potential durability of these changes may be limited by contextual factors, including external accountability, availability of resources, and individual staff attitude. CONCLUSIONS: Mentoring and on-the-job training offer promising alternatives to traditional classroom training and audit-focused supervision for building health workforce capacity. Further evidence regarding comparative effectiveness of these strategies and durability of observed positive change is needed.

Development of a valid and reliable scale to assess parents' beliefs and attitudes about childhood vaccines and their association with vaccination uptake and delay in Ghana.

BACKGROUND: Parents' attitudes and beliefs in vaccination are important to understand for shaping vaccine acceptance and demand interventions. Little research has focused on developing a validated scale to measure parents' attitudes towards vaccinations in low and middle-income countries; Ghana provided an opportunity develop a caregiver vaccination attitudes scale (CVAS) validated against childhood vaccine compliance. METHODS: We conducted a cluster survey of 373 households with children aged 12-35 months of age from Northern Region, Ghana. Caregivers responded to 22 vaccination behavior and belief survey items and provided the child's vaccination status. In exploratory factor analysis (EFA) to assess CVAS content validity, we used parallel analysis to guide the number of factors to extract and principal axis factor analysis for factor extraction. Reliability of the scale was assessed using McDonald's Omega coefficient. Criterion validity of scale and subscales was assessed against receipt of vaccinations by 12 months of age and vaccination delay, using number of days undervaccinated. RESULTS: EFA of CVAS responses resulted in removing 11 of 22 survey items due to loadings <0.30 and development of a 5-factor structure with subscales for Vaccine-Preventable Disease (VPD) Awareness, Vaccine Benefits, Past Behavior, Vaccine Efficacy and Safety, and Trust. The 5 factors accounted for 69% of the common variance and omega coefficients were >0.73 for all subscales. Validity analysis indicated that for every unit increase in the parent's scale score, the odds of the child being vaccinated decreased by 0.58 (95% confidence interval [CI]: 0.37, 0.68) and the number of days under-vaccinated increased by 86 (95%CI: 28, 143). The final 3-factor scale included Vaccine Benefits, Past Behavior, and Vaccine Efficacy and Safety. DISCUSSION: The final CVAS included three factors associated with vaccine compliance in Ghana, although several survey items suggested for use in vaccine acceptance scales were dropped. Replicating this study in several country settings will provide additional evidence to assist in refining a tool for use in routine vaccine acceptance and demand surveillance efforts.

Immunization delivery in the second year of life in Ghana: the need for a multi-faceted approach.

INTRODUCTION: in 2012, pneumococcal conjugate vaccine (PCV), rotavirus vaccine and a second dose of measles-containing vaccine (MCV2) were introduced into the Expanded Program on Immunization (EPI) in Ghana. According to Ghana's EPI schedule, PCV and rotavirus vaccine are given in the first year of life and MCV2 in the second year of life (2YL) at 18 months. Although coverage with the last doses of PCV and rotavirus vaccine reached almost 90% coverage within four years of introduction, MCV2 coverage did not rise above 70%. The World Health Organization Global Measles and Rubella Strategic Plan established a 2020 milestone to achieve at least 95% coverage with the first and second doses of measles-containing vaccine in each district and nationally. We developed a project to address challenges to delivery of immunizations and other child health services at the 18-month visit and throughout the 2YL. METHODS: from March to April 2016, we conducted a cluster survey of households (HHs) with children 24-35 months of age in three regions in Ghana to assess knowledge, attitudes and beliefs among caregivers about immunization during the 2YL and to collect childhood vaccination history data using vaccination cards. Three independent samples were selected from the Northern (NR), Volta (VR), and Greater Accra (GAR) regions. A survey and direct observations were performed a ta representative sample of health facilities (HFs) providing immunization services in the same regions to further characterize barriers to immunization access, utilization and delivery in the 2YL. RESULTS: data on a total of 464 children ages 24-35 months were collected in the HH survey: 211 in NR, 153 in VR, and 100 in GAR (response rate > 99%). First dose of measles-containing vaccine (MCV1) coverage was (NR: 87%, VR: 96%, GAR: 99%); however, MCV2 coverage was lower (NR: 60%, VR: 83%, GAR: 70%). MCV1 to MCV2 dropout was 32% in NR, 14% in VR, and 31% in GAR. Caregiver awareness of immunization against measles was 69% in NR, 75% in VR, and 68% in GAR yet less than half knew the recommended ages for receiving the vaccine, (NR: 4%, VR: 9%, GAR: 44%). Among 160 HFs participating in the survey (>50 in each region), most lacked a defaulter tracing system (NR: 94%,VR: 76%,GAR: 85%). A varying proportion of HCWs correctly indicated how to record a catch-up first dose of MCV administered to an 18-month-old child in the 12-23 month immunization register (NR: 38%, VR: 55%, GAR: 67%) and on the vaccination card (NR: 54%, VR: 53%, GAR: 76%). Although more than half of caregivers would accept text messages, (NR: 57%, VR: 78%, GAR: 96%) including reminders, related to their child's immunizations, < 10% HFs were utilizing this practice. CONCLUSION: challenges encountered with the establishment of an immunization visit beyond the first year of life included knowledge gaps among caregivers, high dropout rates between MCV1 and MCV2 in all study regions, and a lack of defaulter tracing systems in most healthcare facilities providing childhood immunizations. Targeted strategies that promote behavioral, cultural, and policy changes are needed to strengthen 2YL child health service delivery and improve vaccination coverage.

Maternal influenza immunization and birth outcomes of stillbirth and spontaneous abortion: a systematic review and meta-analysis.

Despite strong evidence that maternal influenza vaccination during pregnancy is safe, uptake of influenza vaccination during pregnancy remains low. We identified studies that assessed outcomes of stillbirth or spontaneous abortion after administration of influenza vaccine during pregnancy. We conducted a literature search in November 2013 that yielded 447 total citations. After removal of duplicates and studies deemed not relevant based on the title and abstract, 36 records underwent a full text review and 7 studies were included in the final review. Where possible, adjusted results were included in the meta-analysis. Women in the influenza vaccine group had a lower likelihood of stillbirth (relative risk [RR], 0.73; 95% confidence interval [CI], .55-.96); this association was similar when restricted to the H1N1pdm09 vaccine (RR, 0.69; 95% CI, .53-.90). The pooled estimate for spontaneous abortion was not significant (RR, 0.91; 95% CI, .68-1.22). These analyses add to the evidence base for the safety of influenza vaccination in pregnancy.

Metacognitive therapy in treatment-resistant psychosis: a multiple-baseline study.

BACKGROUND: More effective psychological treatments for psychosis are required. Case series data and pilot trials suggest metacognitive therapy (MCT) is a promising treatment for anxiety and depression. Other research has found negative metacognitive beliefs and thought-control strategies may be involved in the development and maintenance of hallucinations and delusions. The potential of MCT in treating psychosis has yet to be investigated. AIMS: Our aim was to find out whether a short number of MCT sessions would be associated with clinically significant and sustained improvements in delusions, hallucinations, anxiety, depression and subjective recovery in patients with treatment-resistant long-standing psychosis. METHOD: Three consecutively referred patients, each with a diagnosis of paranoid schizophrenia and continuing symptoms, completed a series of multiple baseline assessments. Each then received between 11 and 13 sessions of MCT and completed regular assessments of progress, during therapy, post-therapy and at 3-month follow-up. RESULTS: Two out of 3 participants achieved clinically significant reductions across a range of symptom-based outcomes at end-of-therapy. Improvement was sustained at 3-month follow-up for one participant. CONCLUSIONS: Our study demonstrates the feasibility of using MCT with people with medication-resistant psychosis. MCT was acceptable to the participants and associated with meaningful change. Some modifications may be required for this population, after which a controlled trial may be warranted.

A preliminary exploration of predictors of outcome and cognitive mechanisms of change in cognitive behaviour therapy for psychosis in people not taking antipsychotic medication.

BACKGROUND: Cognitive behaviour therapy (CBT) has been shown to be effective in an open trial for people with psychotic disorders who have not been taking antipsychotic medication. There is little known about predictors of outcome in CBT for psychosis and even less about hypothesised mechanisms of change. METHOD: 20 participants with schizophrenia spectrum disorders received CBT in an exploratory trial. Our primary outcome was psychiatric symptoms measured using the PANSS. Secondary outcomes were dimensions of hallucinations and delusions, self-rated recovery and social functioning, and hypothesised mechanisms of change included appraisals of psychotic experiences, dysfunctional attitudes and cognitive insight. We also measured patient characteristics that may be associated with outcome. RESULTS: T-tests revealed that several of the hypothesised mechanisms did significantly change over the treatment and follow-up periods. Correlational analyses showed that reductions in negative appraisals of psychotic experiences were related to improvements on outcome measures and that shorter duration of psychosis and younger age were associated with greater changes in symptoms. CONCLUSIONS: CBT based on a specific cognitive model appears to change the hypothesised cognitive mechanisms, and these changes are associated with good outcomes. CBT may be more effective for those who are younger with shorter histories of psychosis.