Intent to obtain pediatric influenza vaccine among mothers in four middle income countries.

BACKGROUND: Despite a large burden of influenza in middle income countries, pediatric vaccination coverage remains low. The aims of this study were to (1) describe mothers' knowledge and attitudes about influenza illnesses and vaccination, and (2) identify characteristics associated with mothers' intent to vaccinate their child. METHODS: From 2015 to 2017, infants 0-11 months old in Nicaragua, Philippines, Jordan, and Albania were enrolled from community settings and hospitals. Interviewers administered a questionnaire to their mothers. Mothers of infants aged 6-11 months rated their intention (small-to-moderate vs. large chance) to accept pediatric vaccination if it was offered at no-cost. The importance of knowledge, attitudes, and sociodemographic characteristics in predicting influenza vaccination intention was measured as the mean decrease in Gini index when that factor was excluded from 1000 decision trees in a random forest analysis. RESULTS: In total, 1,308 mothers were enrolled from the community setting and 3,286 from the hospital setting. Prevalence of at least some knowledge of influenza illness ranged from 34% in Philippines to 88% in Albania (in the community sample), and between 23% in Philippines to 88% in Jordan (in the hospital sample). In the community sample, most mothers in Albania (69%) and Philippines (58%) would accept the influenza vaccine, and these proportions were higher in the hospital sample for all countries except Albania (48%) (P < 0.0001). Perceived vaccine safety (mean decrease in Gini index = 61) and effectiveness (55), and perceived knowledge of influenza vaccine (45) were the most important predictors of influenza vaccination intention in models that also included country and community versus hospital sample. CONCLUSION: Intent to vaccinate infants aged 6-11 months in four middle income countries was tied primarily to knowledge of the vaccine and perceptions of vaccine safety and effectiveness. These findings were noted among mothers interviewed in the community and mothers of recently hospitalized infants.

Injuries Reported by Selected Health Facilities During the Arbaeenia Mass Gathering at Babel Governorate, Iraq, 2014: Retrospective Records Analysis.

BACKGROUND: Arbaeenia is the largest religious mass gathering in Iraq. The conditions associated with mass gatherings result in high rates of injury. There have been no prior studies on injuries during the Arbaeenia mass gathering. OBJECTIVE: This study describes the injuries observed during the Arbaeenia mass gathering in Babel Governorate in Iraq between November 24 and December 14, 2014. METHODS: The study was conducted in Babel Governorate at the emergency departments of six public hospitals and two major temporary medical units that were located along the three roads connecting the Middle and Southern Iraqi governorates. We used the Iraq Injury Surveillance System modified form to collect information on injured patients treated in the selected facilities. Data on fatal injuries was obtained from the coroner's office. The following data were collected from the patients: demographics, outcome of injury, place and time of occurrence, mode of evacuation and medical care before arriving at the hospital, duration of travel from place of occurrence to hospital, disposition of non-fatal injury, cause and mode of injury, and whether the injury occurred in connection with the Arbaeenia mass gathering. RESULTS: Information was collected on 1564 injury cases, of which 73 were fatal. About half of the reported nonfatal injuries, 687/1404 (48.9%), and a quarter of fatalities, 18/73 (25%) were related to the Arbaeenia mass gathering (P<.001). Most of the reported injuries were unintentional, 1341/1404 (95.51%), occurred on the street, 864/1323 (65.6%), occurred during the daytime 1103/1174 (93.95 %). Most of those injured were evacuated by means other than ambulance 1107/1206 (91.79%) and did not receive pre-hospital medical care 788/1163 (67.7%). Minor injuries 400/1546 (25.9%) and traffic accidents 394/1546 (25.5%) were the most common types of injuries, followed by falls 270/1546 (17.5%). Among fatal injuries, traffic accidents 38/73 (52%) and violence 18/73 (25%) were the leading causes of death. Mass gathering injuries were more likely to occur among individuals aged 21-40 years (odds ratio [OR] 3.5; 95% CI 2.7-4.5) and >41 years (OR 7.6; 95% CI 5.4-10.6) versus those <21 years; more likely to be unintentional than assault (OR 5.3; 95% CI 1.8-15.5); more likely to happen on the street versus at home (OR 37.7; 95% CI 22.4-63.6); less likely to happen at night than during the day (OR 0.2; 95% CI 0.1-0.4); and less likely to result in hospital admission (OR 0.5; 95% CI 0.3-0.7). CONCLUSIONS: The study shows that most injuries were minor, unintentional, and nonfatal, and most people with injuries had limited access to ambulance transportation and did not require hospitalization.

Shifting dynamics: Changes in the relationship between total fertility rate and contraceptive prevalence rate in Jordan between 2012 and 2017.

Background: Between the two most recent Population and Family Health Surveys, Jordan saw a dramatic decline in the Total Fertility Rate (TFR) from 3.5 to 2.7 in 5.5 years.  Over the same period, modern contraceptive use also declined, from 61.2% to 51.8% among married women.  This decrease in both TFR and the contraceptive prevalence rate (CPR) diverges from the typical relationship seen between these two factors whereby historically as CPR increases, TFR decreases.  This paper explores this unique pattern using multiple methodologies.  Methods: First, we validate the survey data using nationally collected data on fertility and contraceptive distribution.  Second, we look to changes that have historically influenced changes in CPR and TFR, including changes in ideal family size and wanted fertility rates. Third, we explore proximate determinants and other influences on fertility and changes in contraception, examining the changes in the method mix and unmet need; marriage patterns, including the demographics of the married population, spousal separation, and time since last sex; postpartum insusceptibility; infecundity, both primary and secondary; and abortion, to see if any have shifted significantly enough to allow for fertility to decline with less contraceptive use. Results: We find that the decline in fertility in Jordan was driven by a reduction in mistimed or unwanted pregnancies and there was a significant increase in the share of reproductive aged women who are infecund. We also concluded that the changes in fertility and contraceptive use are driven by changes in Jordanian nationals, not by the growing Syrian refugee population. Conclusions: Jordan is not the only country to be experiencing a shift in the typical relationship between CPR and TFR.  Results can inform both future approaches for family planning programs and our expectations regarding what kind of change our family planning investments might buy.

Estimating population immunity to poliovirus in Jordan's high-risk areas.

A community-based serosurvey was conducted among children ages 6-59 to assess population immunity in Jordan's high-risk areas following the Middle East polio outbreak response. The survey was a two-stage cluster-quota sample with high risk areas as the primary sampling units. High-risk areas included border and hard-to-reach areas, and areas with a high proportion of refugees, mobile communities and/or low coverage during previous immunization campaigns. Population immunity to poliovirus was high overall. In high-risk areas, Type 1 seroprevalence = 98% (95% CI = 96, 99), Type 2 = 98% (95% CI = 96, 99) and Type 3 = 96% (95% CI = 94, 98). Seroprevalence was higher in the refugee camps: Type 1 seroprevalence = 99.6% (95% CI = 97.9, 100); Type 2: 99.6% (95% CI = 97.9, 99.9), and Type 3: 100% (95% CI = 100,100). The vigilance that the Jordan Ministry of Health has placed on locating and vaccinating high-risk populations has been successful in maintaining high population immunity and averting polio outbreaks despite the influx of refugees from Syria.

Knowledge, Attitude, and Practices of Food Handlers on Food Safety and Personal Hygiene During Arbaeenia Mass Gathering, Baghdad, Iraq, 2014: Cross-Sectional Study.

BACKGROUND: Millions of pilgrims attend Arbaeenia mass gathering (MG) in Iraq each year. Thousands of individuals work voluntarily at temporary rest areas (locally called Mawakib), distributed in most of Iraq governorates, to provide food and other services to the MG attendees. The potential for improper handling of food at Mawakib increases the risk of waterborne and foodborne diseases. OBJECTIVE: This study was aimed to assess the knowledge, attitude, and practices (KAP) of food handlers in Mawakibs in Baghdad city during Arbaeenia MG. METHODS: A random sample of 100 Mawakibs was selected in Baghdad, 50 from the eastern side (Rusafa) and 50 from the western side (Kerkh), and five food handlers were randomly selected from each Mawakib. A questionnaire was used to collect demographic data and KAP for food safety and personal hygiene. The questionnaire included 25 questions addressing knowledge, 10 addressing attitudes, and 14 addressing practices of the food handlers with respect to food safety and personal hygiene. Questions on knowledge and attitudes were answered through direct interview with the food handlers, whereas the questions on practices were answered through direct observation while handling or serving the food. SPSS version 20 (IBM SPSS Statistics 20) was used for data analysis and describing proportions. RESULTS: There was a varied knowledge of food safety practices among the individuals interviewed. On a scale of 3, the overall average score for both the attitude and practices for food safety and personal hygiene was 2, which corresponds to fair attitude and practices. The attitudes varied significantly by location, age group, and education, whereas the practices varied by location, age groups, employment, and previous experiences. CONCLUSIONS: The food handlers had unsatisfactory attitudes and practices toward food handling and personal hygiene. Their participation in food handling at Mawakib carries a potential risk of spreading foodborne and waterborne diseases. All individuals intending to serve in Mawakib as food handlers should be licensed from the Ministry of Health after completing a formal training in food safety and personal hygiene.

Assessment of Temporary Community-Based Health Care Facilities During Arbaeenia Mass Gathering at Karbala, Iraq: Cross-Sectional Survey Study.

BACKGROUND: Arbaeenia mass gathering (MG) in Karbala, Iraq, is becoming one of the largest MGs in the world. The health care infrastructure in Iraq is inadequately prepared to serve the health needs of the millions of pilgrims. OBJECTIVE: This study aimed to describe the temporary health care facilities installed and run by the local community to provide health care services to Arbaeenia pilgrims in Karbala, Iraq. METHODS: A survey was conducted in all community-based health care facilities located along part of Najaf to Karbala road within Karbala governorate. A structured questionnaire was answered through an interview with the workers and direct observation. Data were collected on staff profile, type of services provided, use of basic infection control measures, medical equipment, drugs and supplies, and the most commonly encountered medical problems. RESULTS: The total number of health care facilities was 120, staffed by 659 workers. Only 18 (15.0%, 18/120) facilities were licensed, and 44.1% (53/120) of the workers were health professionals. The health care workers provided different services including dispensing drugs (370/1692, 21.87%), measuring blood pressure and blood sugar (350/1692, 20.69%), and caring for wounds and injuries (319/1692, 18.85%). Around 97% (116/120) health facilities provided services for musculoskeletal disorders and only 16.7% (20/120) provided services for injuries. The drugs available in the clinic were analgesics, drugs for gastrointestinal and respiratory diseases, and antibiotics, with an availability range of 13.3% to 100.0%. Infection control practices for individual protection, environmental sanitation, and medical waste disposal were available in a range of 18.1% to 100.0%. CONCLUSIONS: Community-based health care facilities experienced a profound shortage of trained human resources and medical supplies. They can significantly contribute to health services if they are adequately equipped and follow standardized operation procedures.

Influenza and respiratory syncytial virus in infants study (IRIS) of hospitalized and non-ill infants aged <1 year in four countries: study design and methods.

BACKGROUND: This multi-country prospective study of infants aged <1 year aims to assess the frequency of influenza virus and respiratory syncytial virus (RSV) infections associated with hospitalizations, to describe clinical features and antibody response to infection, and to examine predictors of very severe disease requiring intensive care. METHODS/DESIGN: We are enrolling a hospital-based cohort and a sample of non-ill infants in four countries (Albania, Jordan, Nicaragua, and the Philippines) using a common protocol. We are currently starting year 2 of a 2- to 3-year study and will enroll approximately 3,000 infants hospitalized for any acute illness (respiratory or non-respiratory) during periods of local influenza and/or RSV circulation. After informed consent and within 24 h of admission, we collect blood and respiratory specimens and conduct an interview to assess socio-demographic characteristics, medical history, and symptoms of acute illness (onset ≤10 days). Vital signs, interventions, and medications are documented daily through medical record abstraction. A follow-up health assessment and collection of convalescent blood occurs 3-5 weeks after enrollment. Influenza and RSV infection is confirmed by singleplex real time reverse transcriptase polymerase chain reaction (rRT-PCR) assays. Serologic conversion will be assessed comparing acute and convalescent sera using hemagglutination inhibition assay for influenza antibodies and enzyme-linked immunosorbent assay (ELISA) for RSV. Concurrent with hospital-based enrollment, respiratory specimens are also being collected (and tested by rRT-PCR) from approximately 1,400 non-ill infants aged <1 year during routine medical or preventive care. DISCUSSION: The Influenza and RSV in Infants Study (IRIS) promises to expand our knowledge of the frequency, clinical features, and antibody profiles of serious influenza and RSV disease among infants aged <1 year, quantify the proportion of infections that may be missed by traditional surveillance, and inform decisions about the potential value of existing and new vaccines and other prevention and treatment strategies.