Healthcare without borders: A cross-sectional study of immigrant and nonimmigrant children admitted to a large public sector hospital in the Gauteng Province of South Africa

BackgroundHuman migration is a worldwide phenomenon that receives considerable attention from the media and healthcare authorities alike. A significant proportion of children seen at public sector health facilities in South Africa (SA) are immigrants, and gaps have previously been noted in their healthcare provision.The objective of the study was to describe the characteristics and differences between the immigrant and SA children admitted to Kalafong Provincial Tertiary Hospital (KPTH), a large public sector hospital in the urban Gauteng Province of SA.Methods and findingsA cross-sectional study was conducted over a 4-month period during 2016 to 2017. Information was obtained through a structured questionnaire and health record review. The enrolled study participants included 508 children divided into 2 groups, namely 271 general paediatric patients and 237 neonates. Twenty-five percent of children in the neonatal group and 22.5% in the general paediatric group were immigrants. The parents/caregivers of the immigrant group had a lower educational level (p < 0.0001 neonatal and paediatric), lower income (neonatal p < 0.001; paediatric p = 0.024), difficulty communicating in English (p < 0.001 neonatal and paediatric), and were more likely residing in informal settlements (neonatal p = 0.001; paediatric p = 0.007) compared to the SA group. In the neonatal group, there was no difference in the number of antenatal care (ANC) visits, type of delivery, gestational age, and birth weight. In the general paediatric group, there was no difference in immunisation and vitamin A supplementation coverage, but when comparing growth, the immigrant group had more malnutrition compared to the SA group (p = 0.029 for wasting). There was no difference in the prevalence of maternal human immunodeficiency virus (HIV) infection, with equally good prevention of mother-to-child transmission (PMTCT) coverage. There was also no difference in reported difficulties by immigrants in terms of access to healthcare (neonatal p = 0.379; paediatric p = 0.246), although a large proportion (10%) of the neonates of immigrant mothers were born outside a medical facility.ConclusionsAlthough there were health-related differences between immigrant and SA children accessing in-hospital care, these were fewer than expected. Differences were found in parental educational level and socioeconomic factors, but these did not significantly affect ANC attendance, delivery outcomes, immunisation coverage, HIV prevalence, or PMTCT coverage. The immigrant population should be viewed as a high-risk group, with potential problems including suboptimal child growth. Health workers should advocate for all children in the community they are serving and promote tolerance, respect, and equal healthcare access.     

Protection Induced by Simultaneous Subcutaneous and Endobronchial Vaccination with BCG/BCG and BCG/Adenovirus Expressing Antigen 85A against Mycobacterium bovis in Cattle

The incidence of bovine tuberculosis (bTB) in the GB has been increasing since the 1980s. Immunisation, alongside current control measures, has been proposed as a sustainable measure to control bTB. Immunisation with Mycobacterium bovis bacillus Calmette-Guerin (BCG) has been shown to protect against bTB. Furthermore, much experimental data indicates that pulmonary local immunity is important for protection against respiratory infections including Mycobacterium tuberculosis and that pulmonary immunisation is highly effective. Here, we evaluated protection against M. bovis, the main causative agent of bTB, conferred by BCG delivered subcutaneously, endobronchially or by the new strategy of simultaneous immunisation by both routes. We also tested simultaneous subcutaneous immunisation with BCG and endobronchial delivery of a recombinant type 5 adenovirus expressing mycobacterial antigen 85A. There was significantly reduced visible pathology in animals receiving the simultaneous BCG/BCG or BCG/Ad85 treatment compared to naïve controls. Furthermore, there were significantly fewer advanced microscopic granulomata in animals receiving BCG/Ad85A compared to naive controls. Thus, combining local and systemic immunisation limits the development of pathology, which in turn could decrease bTB transmission.     

Compliance with diphtheria,tetanus, and pertussis immunisation in Bangladesh: factors identifying high risk groups.

OBJECTIVE--To evaluate factors associated with non-compliance with having second vaccination against diphtheria, tetanus, and pertussis in a treatment centre in Dhaka to determine which children were most at risk of not completing immunisation. DESIGN--Cohort study of infants given first dose of the vaccine and followed up six weeks later to ascertain compliance with having second dose. Factors associated with non-compliance were evaluated. SETTING--Dhaka treatment centre of the International Centre for Diarrhoeal Disease Research, Bangladesh. SUBJECTS--136 unimmunised children aged 6 weeks to 23 months who lived within reach of the treatment centre. At time of the six week follow up 16 of the children could not be traced and seven had died. INTERVENTIONS--All children received their first dose of the vaccine. In each case health education workers had informed the mother about the value of immunisation, and she was given clear instructions to bring the child back after four weeks for the second dose. MAIN OUTCOME MEASURE--Rate of non-compliance with advice to return child for second vaccination. RESULTS--46 of 113 children (41%) received the second dose of the vaccine. Factors most closely associated with mothers'' failure to comply with the second dose were lack of education and low income. Children whose mothers knew most about immunisation at first interview were more likely to have their second dose. CONCLUSIONS--Preventive health care services such as immunisation are appropriately offered in treatment centres, but compliance among children varies with socioeconomic status and mother''s education. Further research should be aimed at ways to make health education more effective among uneducated parents.     

Antibody state to poliovirus in first year university students, 1984.

Circulating antibodies to poliovirus were estimated in a group of 300 British and 84 foreign first year students who registered at the health centre of Nottingham University in 1984. Detectable antibodies to all three poliovirus serotypes were found in 212 (71%) of the British students but in only 47 (56%) of those from abroad. Most of the British students (280; 93%) had been born in 1965 or 1966, when uptake of poliomyelitis vaccine was declining. Immunisation histories showed that 10 British and 29 foreign students (3% and 35%) had no record of any immunisation; only five British and two foreign students, however, were negative for all three poliovirus serotypes. These findings provide evidence that a high proportion of British born people aged 18-29 have adequate circulating poliovirus antibodies despite incomplete immunisation schedules. Though this is reassuring, the absence of antibodies in some students and the lack of previous immunisation against poliomyelitis in 39 suggest that reinforcing doses of vaccine at the time of leaving school or beginning further education are still warranted, particularly for students from other countries. The findings also emphasise the need for accurate immunisation records.     

Advancement of puberty in ewe lambs by active immunisation against inhibin early in life

Active immunisation of lambs early in life with inhibin can advance puberty and increase ovulation rate but these effects appear not to be mediated through changes in FSH concentrations. The aims of this study were to advance puberty in ewe lambs and determine if increased plasma concentrations of gonadotropins are responsible for the advancement of puberty. Ewe lambs were immunised at 3, 7 and 15 weeks of age against either a synthetic inhibin alpha subunit peptide 1–32 conjugated to human serum albumin (HSA), or an inhibin preparation purified from porcine follicular fluid (porcine monoclonal purified inhibin; pMPI), or HSA alone (control immunogen).Immunisation with inhibin alpha peptide 1–32 produced antibodies which bound iodinated native bovine inhibin and advanced puberty (time of first ovulation) and increased ovulation rate but did not significantly increase plasma FSH concentrations, although LH concentrations were lower (P < 0.01) on a number of occasions. In contrast, immunisation with pMPI significantly (P < 0.01) increased FSH and LH concentrations following the first booster immunisation, although FSH was only transiently elevated. Despite these increases in gonadotropins, no advancement of puberty was observed in PMPI immunised ewe lambs.This study confirms that active immunisation of ewe lambs early in life against inhibin advances puberty via a mechanism which does not significantly increase plasma gonadotrophin concentrations. Immunisation to advance puberty also results in persistent increases in ovulation rates in later breeding seasons.     

Variability in airborne bacterial and fungal population in the tertiary health care centre

An investigation of the air quality and the quantity of airborne microbes was conducted in a private and a government tertiary health care centre of Davanagere in the month of November 2011 to assess the level of air borne pathogens. Using a Merck Microbial Air Sampler MAS-100NT, samples were collected in the morning and in the evening from the different environs of the private and government tertiary health care centre. The media used for the study of fungi was sabouraud dextrose agar. Aspergillus spp, Curvularia spp, Alternaria spp, Penicillium spp, Rhizopus spp, Nigrospora spp, and Fusarium spp were found in either of the tertiary health care centre. Aspergillus spp was dominant in the Government tertiary health care centre, and Alternaria spp and Curvularia spp were dominant in the private tertiary health care centre. For the bacteria, quantitative enumeration was done using soyabean casein digest agar and selective media like Escherichia coli and coliform agar and urinary tract infection agar were used in qualitative enumeration. Selected pathogens like E. coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Salmonella enteritidis, Staphylococcus aureus, Proteus mirabilis, and Entirococcus faecalis were found in either of the tertiary health care centre. Maximum number of fungi and bacteria were isolated from emergency ward and general ward of government and private health care centre. There was also considerable difference in the morning and in the evening.     

Effect of investment in malaria control on child mortality in sub-Saharan Africa in 2002-2008

Background

Around 8.8 million children under-five die each year, mostly due to infectious diseases, including malaria that accounts for 16% of deaths in Africa, but the impact of international financing of malaria control on under-five mortality in sub-Saharan Africa has not been examined.

Methods and Findings

We combined multiple data sources and used panel data regression analysis to study the relationship among investment, service delivery/intervention coverage, and impact on child health by observing changes in 34 sub-Saharan African countries over 2002–2008. We used Lives Saved Tool to estimate the number of lives saved from coverage increase of insecticide-treated nets (ITNs)/indoor residual spraying (IRS). As an indicator of outcome, we also used under-five mortality rate. Global Fund investments comprised more than 70% of the Official Development Assistance (ODA) for malaria control in 34 countries. Each $1 million ODA for malaria enabled distribution of 50,478 ITNs [95%CI: 37,774–63,182] in the disbursement year. 1,000 additional ITNs distributed saved 0.625 lives [95%CI: 0.369–0.881]. Cumulatively Global Fund investments that increased ITN/IRS coverage in 2002–2008 prevented an estimated 240,000 deaths. Countries with higher malaria burden received less ODA disbursement per person-at-risk compared to lower-burden countries ($3.90 vs. $7.05). Increased ITN/IRS coverage in high-burden countries led to 3,575 lives saved per 1 million children, as compared with 914 lives in lower-burden countries. Impact of ITN/IRS coverage on under-five mortality was significant among major child health interventions such as immunisation showing that 10% increase in households with ITN/IRS would reduce 1.5 [95%CI: 0.3–2.8] child deaths per 1000 live births.

Conclusions

Along with other key child survival interventions, increased ITNs/IRS coverage has significantly contributed to child mortality reduction since 2002. ITN/IRS scale-up can be more efficiently prioritized to countries where malaria is a major cause of child deaths to save greater number of lives with available resources.     

An Evaluation of the Quality of IMCI Assessments among IMCI Trained Health Workers in South Africa

Background

Integrated Management of Childhood Illness (IMCI) is a strategy to reduce mortality and morbidity in children under 5 years by improving case management of common and serious illnesses at primary health care level, and was adopted in South Africa in 1997. We report an evaluation of IMCI implementation in two provinces of South Africa.

Methodology/Principal Findings

Seventy-seven IMCI trained health workers were randomly selected and observed in 74 health facilities; 1357 consultations were observed between May 2006 and January 2007. Each health worker was observed for up to 20 consultations with sick children presenting consecutively to the facility, each child was then reassessed by an IMCI expert to determine the correct findings. Observed health workers had been trained in IMCI for an average of 32.2 months, and were observed for a mean of 17.7 consultations; 50/77(65%) HW''s had received a follow up visit after training. In most cases health workers used IMCI to assess presenting symptoms but did not implement IMCI comprehensively. All but one health worker referred to IMCI guidelines during the period of observation. 9(12%) observed health workers checked general danger signs in every child, and 14(18%) assessed all the main symptoms in every child. 51/109(46.8%) children with severe classifications were correctly identified. Nutritional status was not classified in 567/1357(47.5%) children.

Conclusion/Significance

Health workers are implementing IMCI, but assessments were frequently incomplete, and children requiring urgent referral were missed. If coverage of key child survival interventions is to be improved, interventions are required to ensure competency in identifying specific signs and to encourage comprehensive assessments of children by IMCI practitioners. The role of supervision in maintaining health worker skills needs further investigation.     

A Multifaceted Intervention to Improve the Quality of Care of Children in District Hospitals in Kenya: A Cost-Effectiveness Analysis

Background

To improve care for children in district hospitals in Kenya, a multifaceted approach employing guidelines, training, supervision, feedback, and facilitation was developed, for brevity called the Emergency Triage and Treatment Plus (ETAT+) strategy. We assessed the cost effectiveness of the ETAT+ strategy, in Kenyan hospitals. Further, we estimate the costs of scaling up the intervention to Kenya nationally and potential cost effectiveness at scale.

Methods and Findings

Our cost-effectiveness analysis from the provider''s perspective used data from a previously reported cluster randomized trial comparing the full ETAT+ strategy (n = 4 hospitals) with a partial intervention (n = 4 hospitals). Effectiveness was measured using 14 process measures that capture improvements in quality of care; their average was used as a summary measure of quality. Economic costs of the development and implementation of the intervention were determined (2009 US$). Incremental cost-effectiveness ratios were defined as the incremental cost per percentage improvement in (average) quality of care. Probabilistic sensitivity analysis was used to assess uncertainty. The cost per child admission was US$50.74 (95% CI 49.26–67.06) in intervention hospitals compared to US$31.1 (95% CI 30.67–47.18) in control hospitals. Each percentage improvement in average quality of care cost an additional US$0.79 (95% CI 0.19–2.31) per admitted child. The estimated annual cost of nationally scaling up the full intervention was US$3.6 million, approximately 0.6% of the annual child health budget in Kenya. A “what-if” analysis assuming conservative reductions in mortality suggests the incremental cost per disability adjusted life year (DALY) averted by scaling up would vary between US$39.8 and US$398.3.

Conclusion

Improving quality of care at scale nationally with the full ETAT+ strategy may be affordable for low income countries such as Kenya. Resultant plausible reductions in hospital mortality suggest the intervention could be cost-effective when compared to incremental cost-effectiveness ratios of other priority child health interventions. Please see later in the article for the Editors'' Summary     

Coverage and Quality of Antenatal Care Provided at Primary Health Care Facilities in the ‘Punjab’ Province of ‘Pakistan’

Background

Antenatal care is a very important component of maternal health services. It provides the opportunity to learn about risks associated with pregnancy and guides to plan the place of deliveries thereby preventing maternal and infant morbidity and mortality. In ‘Pakistan’ antenatal services to rural population are being provided through a network of primary health care facilities designated as ''Basic Health Units and Rural Health Centers. Pakistan is a developing country, consisting of four provinces and federally administered areas. Each province is administratively subdivided in to ‘Divisions’ and ‘Districts’. By population ‘Punjab’ is the largest province of Pakistan having 36 districts. This study was conducted to assess the coverage and quality antenatal care in the primary health care facilities in ‘Punjab’ province of ‘Pakistan’.

Methods

Quantitative and Qualitative methods were used to collect data. Using multistage sampling technique nine out of thirty six districts were selected and 19 primary health care facilities of public sector (seventeen Basic Health Units and two Rural Health Centers were randomly selected from each district. Focus group discussions and in-depth interviews were conducted with clients, providers and health managers.

Results

The overall enrollment for antenatal checkup was 55.9% and drop out was 32.9% in subsequent visits. The quality of services regarding assessment, treatment and counseling was extremely poor. The reasons for low coverage and quality were the distant location of facilities, deficiency of facility resources, indifferent attitude and non availability of the staff. Moreover, lack of client awareness about importance of antenatal care and self empowerment for decision making to seek care were also responsible for low coverage.

Conclusion

The coverage and quality of the antenatal care services in ‘Punjab’ are extremely compromised. Only half of the expected pregnancies are enrolled and out of those 1/3 drop out in follow-up visits.     

Measles immunisation rates and the good practice allowance.

The recent discussion document on primary health care proposes that a good practice allowance is paid to general practitioners based in part on the uptake of immunisation by patients. The variation between and the validity of practice immunisation rates for measles as determined by one district health authority''s child health computer are assessed. In areas of low population mobility district health authority rates may be sufficiently accurate to base a good practice allowance on but should not be used until the social environment of each practice can also be characterised. In areas of high mobility intermittent surveys may be a preferable method of auditing performance.     

Intestinal Parasites in Children from a Day Care Centre in Matanzas City,Cuba

Background

Intestinal parasitic infections are widely distributed throughout the world and children are the most affected population. Day care centres are environments where children have proven to be more susceptible to acquiring IP.

Methods and Principal Findings

A cross-sectional study was carried to determine the prevalence of intestinal parasites in stool samples among children who attend to a day care centre in an urban area of Matanzas city, Cuba, from March to June 2012. 104 children under five years old were included on the study after informed consent form was signed by parents or legal guardians. Three fresh faecal samples were collected from each child in different days and were examined by direct wet mount, formalin-ether, and Kato- Katz techniques. Data relating to demography, socioeconomic status, source of drinking water, and personal hygiene habits were also collected using a standardized questionnaire. In total, 71.1% of children harbored at least one type of intestinal parasite and 47 (45.2%) were infected by more than one species. Giardia duodenalis and Blastocystis sp. were the most common parasites found, with prevalence rates of 54.8% and 38.5% respectively.

Conclusions

Despite public health campaigns, improvement in the level of education, and the availability of and access to medical services in Cuba infections by intestinal protozoan is high in this centre. Almost nothing is published regarding intestinal parasites in Matanzas province during the last 40 years so this work could also be the initial point to carry out other studies to clarify the IP status in this region.     

Benefits and risks of childhood immunisations in developing countries.

The ratio of benefit to harm from an imaginary, modest immunisation programme in a developing country and the numbers of lives likely to be saved and severe handicaps prevented have been estimated. Immunisation is much more likely to benefit children than to harm them, and health workers can be confidently encouraged not to withhold the benefits of immunisation from most children.     

Factors affecting uptake of measles,mumps, and rubella immunisation.

OBJECTIVE--To study factors affecting uptake of measles, mumps, and rubella immunisation. DESIGN--Cohort study using data from computerised child health systems. SETTING--10 health districts in North East Thames and North West Thames regions. SUBJECTS--7841 children born in January to March 1990 and resident in the districts up till the end of October 1991. MAIN OUTCOME MEASURES--Overall uptake of measles, mumps, and rubella immunisation, variation of uptake among groups of children, and odds ratio of being vaccinated against measles, mumps, and rubella. RESULTS--The overall uptake rate of measles, mumps, and rubella immunisation for the study cohort in the 10 districts was 82%. Wide variation was identified among children with different demographic characteristics. Lower uptake was associated with absent or incomplete primary immunisation, including omission of pertussis vaccine. Other factors affecting uptake included the type of resident district, birth order, where registered for immunisation (general practitioner or clinic), and one parent family status. CONCLUSIONS--Many districts have difficulties in meeting the 90% target for measles, mumps, and rubella immunisation, mainly because of the characteristics of their local population. To increase overall coverage, the health service should target families with adverse factors, especially those whose children have missed previous immunisations.     

Analysis of the Maternal and Child Health Care Status in Suizhou City,Hubei Province,China, from 2005 to 2011

Background

Improving the health and well-being of women and children has long been a common goal throughout the world. From 2005 to 2011, Suizhou City had an annual average of 22,405 pregnant and parturient women (1.04% of the population) and 98,811 children under 5 years old (4.57% of the population). Understanding the status of maternal and child health care in Suizhou City during such period can provide the local health administrative department valid scientific bases upon which to construct effective policies.

Methods

Various types of annual reports on maternal and child health care were collected and analyzed retrospectively.

Results

Mortality rates for infants and children under 5 years showed a declining trend, while the rates of newborn home visiting, maternal health service coverage, and children health systematic management increased annually in Suizhou City from 2005 to 2011. The incidence of birth defect increased from 2.42‰ in 2005 to 3.89‰ in 2011. The maternal mortality ratio (MMR) fluctuated from 8.39/100,000 to 28.77/100,000, which was much lower than the national MMR (30.0/100,000 in 2010). The rates of hospitalized delivery and births attended by trained health personnel for pregnant women increased to more than 90% in the past five years.

Conclusions

The improvements in maternal and child health care work in Suizhou City are worthy of recognition. Thus, the government should continue to increase funding in these areas to promote the complete enhancement of the maternal and child health care system.     

Primary Health Care Utilization by the Mexican Indigenous Population: The Role of the Seguro Popular in Socially Inequitable Contexts

Objective

To analyze the relationship between primary health care utilization and extended health insurance coverage under the Seguro Popular (SP) among Mexican indigenous people.

Methodology

A cross-sectional analysis was conducted using data from the Mexican National Nutrition Survey 2012 (n = 194,758). Quasi-experimental matching methods and nonlinear regression probit models were used to estimate the influence of SP on primary health care utilization.

Results

25% of the Mexican population reported having no health insurance coverage, while 59% of indigenous versus 35% of non-indigenous reported having SP coverage. Health problems were reported by 13.9% of indigenous vs. 10.5% of non-indigenous; of these, 52.8% and 57.7% respectively, received primary health care (p<0.05). Economic barriers were the most frequent reasons for not using primary health care services. The probability of utilizing primary health care services was 11.5 percentage points higher (p<0.01) for indigenous SP affiliates in comparison with non-indigenous, in similar socioeconomic conditions.

Conclusion

Socioeconomic conditions, not ethnicity per-se, determine whether people utilize primary health care services. Therefore, SP can be conceived as a public policy strategy which acts as a social buffer by enhancing health care utilization regardless of ethnicity. Further analysis is required to explore the potential gaps as a result of SP coverage among socially vulnerable groups.     

Countdown to 2015: Tracking Maternal and Child Health Intervention Targets Using Lot Quality Assurance Sampling in Bauchi State Nigeria

Background

Improving maternal and child health remains a top priority in Nigeria’s Bauchi State in the northeastern region where the maternal mortality ratio (MMR) and infant mortality rate (IMR) are as high as 1540 per 100,000 live births and 78 per 1,000 live births respectively. In this study, we used the framework of the continuum of maternal and child care to evaluate the impact of interventions in Bauchi State focused on improved maternal and child health, and to ascertain progress towards the achievement of Millennium Development Goals (MDGs) 4 and 5.

Methods

At baseline (2012) and then at follow-up (2013), we randomly sampled 340 households from 19 random locations in each of the 20 Local Government Areas (LGA) of Bauchi State in Northern Nigeria, using the Lot Quality Assurance Sampling (LQAS) technique. Women residents in the households were interviewed about their own health and that of their children. Estimated LGA coverage of maternal and child health indicators were aggregated across the State. These values were then compared to the national figures, and the differences from 2012 to 2014 were calculated.

Results

For several of the indicators, a modest improvement from baseline was found. However, the indicators in the continuum of care neither reached the national average nor attained the 90% globally recommended coverage level. The majority of the LGA surveyed were classifiable as high priority, thus requiring intensified efforts and programmatic scale up.

Conclusions

Intensive scale-up of programs and interventions is needed in Bauchi State, Northern Nigeria, to accelerate, consolidate and sustain the modest but significant achievements in the continuum of care, if MDGs 4 and 5 are to be achieved by the end of 2015. The intentional focus of LGAs as the unit of intervention ought to be considered a condition precedent for future investments. Priority should be given to the re-allocating resources to program areas and regions where coverage has been low. Finally, systematic considerations need to be given to the design of strategies that address the demand for health services.     

Focus: Rare Disease: Psychosocial Functioning in Siblings of Children With Rare Disorders Compared to Controls

Siblings of children with chronic disorders are at increased risk of psychosocial problems. The risk may be exacerbated when the chronic disorder is rare and limited medical knowledge is available, due to more uncertainty and feelings of isolation. We examined mental health, parent-child communication, child-parent relationship quality, and social support among 100 children aged 8 to 16 years (M age 11.5 years, SD = 2.2; 50.0% boys, 50.0% girls). Fifty-six were siblings of children with rare disorders, and 44 were controls. The siblings of children with rare disorders (herein, siblings) were recruited from a resource centre for rare disorders and comprised siblings of children with a range of rare disorders including neuromuscular disorders and rare chromosomal disorders with intellectual disability. Controls were recruited from schools. Self-reported child mental health was significantly poorer for siblings compared to controls (effect size difference d = 0.75). Parent-reported child mental health was not significantly different between the groups (d = -0.06 to 0.16). Most child-parent relationships (anxiety/avoidance; mothers/fathers) were significantly poorer for siblings compared to controls (d = 0.47 to 0.91). There was no difference between groups in anxious relation with mother. Parent-child communication was significantly poorer for siblings compared to controls (d = -0.87 to -0.75). Social support was significantly poorer for siblings compared to controls (d = 0.61). We conclude that siblings of children with rare disorders display more psychosocial problems than controls. Interventions are indicated to prevent further maladjustment for siblings.     

A statistical model of the international spread of wild poliovirus in Africa used to predict and prevent outbreaks

Background

Outbreaks of poliomyelitis in African countries that were previously free of wild-type poliovirus cost the Global Polio Eradication Initiative US$850 million during 2003–2009, and have limited the ability of the program to focus on endemic countries. A quantitative understanding of the factors that predict the distribution and timing of outbreaks will enable their prevention and facilitate the completion of global eradication.

Methods and Findings

Children with poliomyelitis in Africa from 1 January 2003 to 31 December 2010 were identified through routine surveillance of cases of acute flaccid paralysis, and separate outbreaks associated with importation of wild-type poliovirus were defined using the genetic relatedness of these viruses in the VP1/2A region. Potential explanatory variables were examined for their association with the number, size, and duration of poliomyelitis outbreaks in 6-mo periods using multivariable regression analysis. The predictive ability of 6-mo-ahead forecasts of poliomyelitis outbreaks in each country based on the regression model was assessed. A total of 142 genetically distinct outbreaks of poliomyelitis were recorded in 25 African countries, resulting in 1–228 cases (median of two cases). The estimated number of people arriving from infected countries and <5-y childhood mortality were independently associated with the number of outbreaks. Immunisation coverage based on the reported vaccination history of children with non-polio acute flaccid paralysis was associated with the duration and size of each outbreak, as well as the number of outbreaks. Six-month-ahead forecasts of the number of outbreaks in a country or region changed over time and had a predictive ability of 82%.

Conclusions

Outbreaks of poliomyelitis resulted primarily from continued transmission in Nigeria and the poor immunisation status of populations in neighbouring countries. From 1 January 2010 to 30 June 2011, reduced transmission in Nigeria and increased incidence in reinfected countries in west and central Africa have changed the geographical risk of polio outbreaks, and will require careful immunisation planning to limit onward spread. Please see later in the article for the Editors'' Summary