Vaccine implementation factors affecting maternal tetanus immunization in low- and middle-income countries: Results of the Maternal Immunization and Antenatal Care Situational Analysis (MIACSA) project.

OBJECTIVES: To examine the characteristics of existing maternal tetanus immunization programmes for pregnant women in low- and middle-income countries (LMICs) and to identify and understand the challenges, barriers and facilitators associated with maternal vaccine service delivery that may impact the introduction and implementation of new maternal vaccines in the future. DESIGN: A mixed methods, cross sectional study with four data collection phases including a desk review, online survey, telephone and face-to-face interviews and in country visits. SETTING: LMICs. RESULTS: The majority of countries (84/95; 88%) had a maternal tetanus immunization policy. Countries with high protection at birth (PAB) were more likely to report tetanus toxoid-containing vaccine (TTCV) coverage targets > 90%. Less than half the countries included in this study had a TTCV coverage target of > 90%. Procurement and distribution of TTCV was nearly always the responsibility of the Expanded Programme on Immunization (EPI), however planning and management of maternal immunization was often shared between EPI and Maternal, Newborn and Child Health (MNCH) programmes. Receipt of TTCV at the same time as the antenatal care visit correlated with high PAB. Most countries (81/95; 85%) had an immunization safety surveillance system in place although only 11% could differentiate an adverse event following immunization (AEFI) in pregnant and non-pregnant women. CONCLUSIONS: Recommendations arising from the MIACSA project to strengthen existing services currently delivering maternal tetanus immunization in LMICs include establishing and maintaining vaccination targets, clearly defining responsibilities and fostering collaborations between EPI and MNCH, investing in strengthening the health workforce, improving the design and use of existing record keeping for immunization, adjusting current AEFI reporting to differentiate pregnant women and endeavoring to integrate the provision of TTCV within ANC services where appropriate.

Antenatal care service delivery and factors affecting effective tetanus vaccine coverage in low- and middle-income countries: Results of the Maternal Immunisation and Antenatal Care Situational analysis (MIACSA) project.

OBJECTIVES: To map the integration of existing maternal tetanus immunization programmes within antenatal care (ANC) services for pregnant women in low- and middle-income countries (LMICs) and to identify and understand the challenges, barriers and facilitators associated with high performance maternal vaccine service delivery. DESIGN: A mixed methods, cross sectional study with four data collection phases including a desk review, online survey, telephone and face-to-face interviews and in country visits was undertaken between 2016 and 2018. Associations of different service delivery process components with protection at birth (PAB) and with country groups were established. PAB was defined as the proportion of neonates protected at birth against neonatal tetanus. Regression analysis and structural equation modelling was used to assess associations of different variables with maternal tetanus immunization coverage. Latent class analysis (LCA), was used to group country performance for maternal immunization, and to address the problem of multicollinearity. SETTING: LMICs. RESULTS: The majority of LMICs had a policy on recommended number of ANC visits, however most were yet to implement the WHO guidelines recommending eight ANC contacts. Countries that recommended > 4 ANC contacts were more likely to have high PAB > 90%. Passive disease surveillance was the most common form of disease surveillance performed but the maternal and neonatal morbidity and mortality indicators recorded differed between countries. The presence of user fees for antenatal care and maternal immunization was significantly associated with lower PAB (<90%). CONCLUSIONS: Recommendations include implementing the current WHO ANC guideline to facilitate increased opportunities for vaccination during each pregnancy. Improved utilisation of ANC services by increasing the demand side by increasing the quality of services, reducing any associated costs and supporting user fee exemptions, or the supply side can also enhance utilisation of ANC services which are positioned as an ideal platform for delivery of maternal vaccines.

Chronic hepatitis B infection and the risk of gestational diabetes: a cross-sectional study.

OBJECTIVE: An estimated two billion people worldwide live with hepatitis B virus (HBV) infection. Many of these are women of reproductive age. Studies that have examined pregnancy outcomes in women living with HBV have reported conflicting results in relation to the incidence of gestational diabetes (GDM). The aim of this study is to examine if gestational diabetes is more common in women with chronic HBV residing in a non-Asian country. DESIGN: Cross-sectional study. SETTING: Victoria, Australia. POPULATION: All singleton births between 2009 and 2017. METHODS: Poisson regression was performed to determine whether gestational diabetes is more common in women with HBV than in women without HBV taking into account other risk factors such as maternal age, body mass index (BMI), parity and country of birth. MAIN OUTCOME MEASURE: Gestational diabetes diagnosis in women with chronic HBV infection. RESULTS: For women with HBV, the unadjusted incidence risk ratio for GDM was 1.75 (95% CI 1.6-1.9). After adjusting for region of birth, BMI, parity, age and smoking, the adjusted incidence risk ratio was 1.2 (95% CI 1.1-1.3). The highest incidence (37.1%) of GDM was in women with HBV and a BMI of >40. CONCLUSIONS: The findings from this study confirm an association between HBV and GDM. TWEETABLE ABSTRACT: HBV is associated with GDM with an incidence risk ratio for GDM of 1.75 (95% CI 1.6-1.9).

The barriers to linkage and retention in care for women living with HIV in an high income setting where they comprise a minority group.

Women comprise a minority population of individuals living with HIV in Australia, and are often poorly represented in research and clinical trials so their needs remain largely unknown. Data suggests that they are diagnosed later than men and start antiretroviral therapy at a lower CD4 cell count. This raises the question whether there are sex specific barriers to linkage and retention in care. This study analyzed 484 surveys received from clinicians collecting demographic, virological, and reproductive health data along with perceived barriers to linkage and retention in care. Most women (67%) were estimated to have been linked into care within 28 days of diagnosis. For women who were not linked into care for more than 28 days, the most commonly reason cited was fear of disclosure to others, followed by fear of disclosure to their partner. The main reasons given for non-retention in care were related to transport, carer responsibilities, financial pressure, health beliefs and concern about stigma or disclosure.

Vaccine decision-making begins in pregnancy: Correlation between vaccine concerns, intentions and maternal vaccination with subsequent childhood vaccine uptake.

INTRODUCTION: Maternal and childhood vaccine decision-making begins prenatally. Amongst pregnant Australian women we aimed to ascertain vaccine information received, maternal immunisation uptake and attitudes and concerns regarding childhood vaccination. We also aimed to determine any correlation between a) intentions and concerns regarding childhood vaccination, (b) concerns about pregnancy vaccination, (c) socioeconomic status (SES) and (d) uptake of influenza and pertussis vaccines during pregnancy and routine vaccines during childhood. METHODS: Women attending public antenatal clinics were recruited in three Australian states. Surveys were completed on iPads. Follow-up phone surveys were done three to six months post delivery, and infant vaccination status obtained via the Australian Childhood Immunisation Register (ACIR). RESULTS: Between October 2015 and March 2016, 975 (82%) of 1184 mothers consented and 406 (42%) agreed to a follow up survey, post delivery. First-time mothers (445; 49%) had significantly more vaccine concerns in pregnancy and only 73% had made a decision about childhood vaccination compared to 89% of mothers with existing children (p-value<0.001). 66% of mothers reported receiving enough information during pregnancy on childhood vaccination. In the post delivery survey, 46% and 82% of mothers reported receiving pregnancy influenza and pertussis vaccines respectively. The mother's degree of vaccine hesitancy and two attitudinal factors were correlated with vaccine uptake post delivery. There was no association between reported maternal vaccine uptake or SES and childhood vaccine uptake. CONCLUSION: First time mothers are more vaccine hesitant and undecided about childhood vaccination, and only two thirds of all mothers believed they received enough information during pregnancy. New interventions to improve both education and communication on childhood and maternal vaccines, delivered by midwives and obstetricians in the Australian public hospital system, may reduce vaccine hesitancy for all mothers in pregnancy and post delivery, particularly first-time mothers.

Phantom gallbladders.

The sensitivity of ultrasonography for detecting gallstones is high, but mishaps can occur. The three false positive cases we describe here illustrate problems which may be encountered in interpreting ultrasound images and in communication between the clinician, patient and ultrasonographer.

Do children waiting for tonsillectomy grow out of their tonsillitis?

OBJECTS: to determine whether children may grow out of recurrent acute tonsillitis. METHODS: the parents of 100 children aged 2-14 on the elective waiting list for tonsillectomy were given a postal or telephone interview in November 1989. RESULTS: data from the parents of 92 respondents showed the children had been on the waiting list for a mean of seven months. Ninety-two percent still suffered from sore throats and 79% had had at least one course of antibiotics within the last six months. There was no reduction in the frequency of sore throat or the number of courses of antibiotics in children who had waited longer. CONCLUSIONS: there was no justification for claiming that long waiting lists for tonsillectomy are frequently associated with resolution of recurrent acute tonsillitis.

Surgery of snoring.

Habitual, loud snoring is common in the adult population, and may be the only symptom of the more serious Obstructive Sleep Apnoea syndrome. We report here our results of uvulo-palato-pharyngo-plasty (UPPP), with or without nasal surgery, for snoring. Quantitative grading of the severity of the snoring shows that all patients were cured of symptomatic snoring, but that snoring was not altogether abolished in all patients.

Surgery for pharyngeal pouch.

Diverticulectomy for pharyngeal pouch requires several days in hospital and carries a risk of postoperative fistula formation. Small to moderate sized pouches can be inverted easily. Experience with this technique has been encouraging and results are reported here. Large pouches of long standing probably should be excised rather than inverted.

Evaluation of the Du Pont aca alpha-amylase procedure.

The procedure used with the Du Pont aca for alpha-amylase (1,4,-alpha-D-glucan glucanohydrolase, EC 3.2.1.1) was evaluated in our laboratory and compared with the Roche Diagnostics "Amylochrome" and Perkin-Elmer Coleman 91 amylase assays. The within-run coefficients of variation (CV) for samples of fresh normal sera were: aca 5.8% and 4.3% on two different lots of reagent, Amylochrome 7.4%, and Coleman 91 3.3%. In sera with abnormally high amylase activity, the respective CV's were: aca, 1.2% and 0.8%; Amylochrome, 2.0%; and Coleman 91, 2.8%. Day-to-day precision studies on fresh and lyophilized normal and abnormal sera gave CV's in the following ranges: aca, 1.8% to 6.7%; Amylochrome, 3.0% to 5.2%; and Coleman 91, 4.5% to 5.9%. Results by the aca procedure were linearly related to activity to about 10-fold the upper limit of normal amylase activity. For serum, correlations were: r = 0.977 for aca vs. Coleman 91 and r = 0.974 for aca vs. Amylochrome. For urine they were: r = 0.978 for aca vs. Coleman 91 and r = 0.975 for aca vs. Amylochrome. Mean recovery from 53 supplemented samples was 98%. Icterus, hemolysis, and lipemia did not interfere with method correlation of aca vs. Coleman 91 or Amylochrome.

Evaluation of the Beckman "System TR enzyme Analyzer".

We evaluated 16 claims made by Beckman Instruments, Inc. for its Enzyme Analyzer (System TR), under a rigid written protocol for the Product Evaluation Subcommittee of the Standards Committee of the College of American Pathologists. We found the following to be within the company's specifications: (a) accuracy and precision of the temperature control; (b) accuracy and precision of the sample and reagent pipets; (c) instrument precision, both within-run and between-day; (d) carry-over from a sample with activity greater than 1000 U/liter; (e) instrument-to-instrument variation; (f) analytical linearity; (g) analysis time; (h) correlation of the instrument-printed answer with the activity calculated manually from a strip-chart recorder; (i) precision of the instrument's built-in electronic "standard"; (j) effectiveness of the over-range indicators; and (k) correlation between results of these enzyme assay methods and those for kinetic methods used in our laboratory. The instrument performed well.