Administrative Coverage Research Articles

Epidemiological situation of pertussis and strategies to control it: Argentina, 2002-2011.

Pertussis is a challenge for public health. To describe pertussis-related morbidity and mortality and immunization coverage for the 2002-2011 period, profile of cases for 2011, and control strategies implemented by the Ministry of Health (MoH) of Argentina. Descriptive, epidemiological surveillance study. Morbidity data were obtained from the National Health Surveillance System, while mortality data were obtained from the MoH's Health Statistics and Information Department and official jurisdictional reports. Administrative immunization coverage was used based on the data provided by the MoH's jurisdictions. The Epi Info software, version 7.1.2, was used for analysis. The number of reported cases of pertussis increased between 2002 and 2011, reaching its peak in 2011: an incidence of 16 x 100 000 inhabitants, and 76 deaths. Most deaths occurred in infants younger than 1 year old. Immunization coverage achieved at a national level with the third dose and the dose administered at the time of starting primary education was >90%, while the coverage achieved with the first booster dose was 80%-90%. In 2011, 2821 confirmed cases were reported (incidence of 7 x 100 000 inhabitants): 84% in infants <1 year old; 76 deaths: 97% in infants <1 year old (60.5% in infants <2 months old). Among the strategies that were deployed, a total of 906 clinical nodes and 405 laboratory nodes were consolidated; the use of the polymerase chain reaction as a diagnostic method and the differential classification of cases were implemented, and additional vaccine doses were administered. The number of pertussis cases increased between 2002 and 2011; the highest morbidity and mortality occurred in infants younger than 1 year old; immunization coverage reached 80%-90%. . The highest number of pertussis-related deaths was recorded in 2011. The MoH strengthened the epidemiological surveillance and set guidelines for control measures.

Situación epidemiológica de coqueluche y estrategias para su control. Argentina, 2002-2011

Pertussis is a challenge for public health. To describe pertussis-related morbidity and mortality and immunization coverage for the 2002-2011 period, profile of cases for 2011, and control strategies implemented by the Ministry of Health (MoH) of Argentina. Descriptive, epidemiological surveillance study. Morbidity data were obtained from the National Health Surveillance System, while mortality data were obtained from the MoH's Health Statistics and Information Department and official jurisdictional reports. Administrative immunization coverage was used based on the data provided by the MoH's jurisdictions. The Epi Info software, version 7.1.2, was used for analysis. The number of reported cases of pertussis increased between 2002 and 2011, reaching its peak in 2011: an incidence of 16 x 100 000 inhabitants, and 76 deaths. Most deaths occurred in infants younger than 1 year old. Immunization coverage achieved at a national level with the third dose and the dose administered at the time of starting primary education was >90%, while the coverage achieved with the first booster dose was 80%-90%. In 2011, 2821 confirmed cases were reported (incidence of 7 x 100 000 inhabitants): 84% in infants <1 year old; 76 deaths: 97% in infants <1 year old (60.5% in infants <2 months old). Among the strategies that were deployed, a total of 906 clinical nodes and 405 laboratory nodes were consolidated; the use of the polymerase chain reaction as a diagnostic method and the differential classification of cases were implemented, and additional vaccine doses were administered. The number of pertussis cases increased between 2002 and 2011; the highest morbidity and mortality occurred in infants younger than 1 year old; immunization coverage reached 80%-90%. . The highest number of pertussis-related deaths was recorded in 2011. The MoH strengthened the epidemiological surveillance and set guidelines for control measures.

From the parents’ perspective: a user-satisfaction survey of immunization services in Guatemala

BackgroundImmunization coverage levels in Guatemala have increased over the last two decades, but national targets of ≥95% have yet to be reached. To determine factors related to undervaccination, Guatemala’s National Immunization Program conducted a user-satisfaction survey of parents and guardians of children aged 0–5 years. Variables evaluated included parental immunization attitudes, preferences, and practices; the impact of immunization campaigns and marketing strategies; and factors inhibiting immunization.MethodsBased on administrative coverage levels and socio-demographic indicators in Guatemala’s 22 geographical departments, five were designated as low-coverage and five as high-coverage areas. Overall, 1194 parents and guardians of children aged 0–5 years were interviewed in these 10 departments. We compared indicators between low- and high-coverage areas and identified risk factors associated with undervaccination.ResultsOf the 1593 children studied, 29 (1.8%) were determined to be unvaccinated, 458 (28.8%) undervaccinated, and 1106 (69.4%) fully vaccinated. In low-coverage areas, children of less educated (no education: RR = 1.49, p = 0.01; primary or less: 1.39, p = 0.009), older (aged >39 years: RR =1.31, p = 0.05), and single (RR = 1.32, p = 0.03) parents were more likely to have incomplete vaccination schedules. Similarly, factors associated with undervaccination in high-coverage areas included the caregiver’s lack of education (none: RR = 1.72, p = 0.0007; primary or less: RR = 1.30, p = 0.05) and single marital status (RR = 1.36, p = 0.03), as well as the child’s birth order (second: RR = 1.68, p = 0.003). Although users generally approved of immunization services, problems in service quality were identified. According to participants, topics such as the risk of adverse events (47.4%) and next vaccination appointments (32.3%) were inconsistently communicated to parents. Additionally, 179 (15.0%) participants reported the inability to vaccinate their child on at least one occasion. Compared to high-coverage areas, participants in low-coverage areas reported poorer service, longer wait times, and greater distances to health centers. In high-coverage areas, participants reported less knowledge about the availability of services.ConclusionsGenerally, immunization barriers in Guatemala are related to problems in accessing and attaining high-quality immunization services rather than to a population that does not adequately value vaccination. We provide recommendations to aid the country in maintaining its achievements and addressing new challenges.

Improving Physician Documentation of Hospice Eligibility: Findings of an Ongoing Multi-State Effort (FR402)

1.Describe prognostic criteria for determining hospice eligibility, as defined by the various Medicare Administrative Contractors' Local Coverage Determinations.2.Describe incorporating these criteria into key elements needed for optimally documenting hospice eligibility, as derived from feedback from an ongoing, multi-state performance improvement effort.3.Discuss effective techniques for modifying clinician behavior to improve documentation as well as potential pitfalls and hazards of not continuously monitoring documentation performance. Determining prognosis is an integral function for clinicians involved in hospice and palliative medicine. Because the Medicare Hospice Benefit defines hospice eligibility in terms of prognosis, proper and optimal documentation of this by clinicians is vital both for clinical accuracy and for financial viability of the hospice program. We will describe our 3-year, ongoing experience involving more than 450 hospice medical directors (HMDs) in 31 states across all four of the Medicare Administrative Contractors and their respective, different Local Coverage Determinations. In an ongoing fashion, we determine our internal performance, which is compared to published standards and to other non-published feedback from the multiple regulatory auditing entities. Because of our size, we are virtually always undergoing external reviews somewhere across our organization. This information has led to key elements being identified and recommended for optimal documentation. By using standard performance improvement techniques, education and feedback is provided to HMDs and other hospice clinicians regarding both clinical standards as well as documentation methods. This presentation will describe the techniques found to be most effective in modifying clinician behavior to improve documentation. We will also describe processes for minimizing and clarifying potentially contradictory documentation elements across time or among different clinicians. Results of our effort have substantially improved internal compliance scores as well as resulting in significantly better external regulatory audit findings. The key elements, processes, and forms used for our project will all be shared.

Impact d’un vaccin conjugué antiméningococcique « A » sur les méningites bactériennes notifiées à l’ouest du Burkina Faso (2009–2012)

Burkina Faso is a sub-saharan African country completely included in the meningococcal meningitis belt. The western part of the country suffered from many meningococcal A epidemics, in spite of reactive collective campaigns with polysaccharide A vaccine. On 6th December 2010, Burkina Faso was the first African country to conduct a collective vaccination campaign of all the 1-29 years old population with a new conjugated meningococcal Avaccine (MenAfriVac™). Before this campaign, in Western Burkina (4,064,928 inhabitants, 27.5% of total population), a rehearsal of the staff of all peripheral medical laboratories has been conducted, with delivery of laboratory equipment, reactants, and possibility to transfer CSF specimens at the central level to confirm bacteriologic species in cause by latex, culture and PCR analysis. For this campaign, an administrative coverage of 100.3% was reached. A nearly complete disappearance of meningitis due to meningococcus A was recorded, but an increase of cases due to meningococcus X, W135. With the increase of quality of surveillance, and MenAfriVac™ vaccination showed its beneficial effect on meningococcus A meningitis. If we want however to impact on the number of recorded acute bacteriological meningitis, we will have to use multi-antigenic, if possible conjugated, meningococcal vaccines against locally circulating meningococcal species, the number of pneumococcal meningitis being contained by the recent inclusion in EPI of a 13-valent conjugated pneumococcal vaccine.

A Comparison of National Immunization Programme Target Population Estimates with Data from an Independent Source and Differences in Computed Coverage Levels for the Third Dose of DTP Containing Vaccine

Background: Comparison of target populations for immunization used by national immunization programmes with independent sources can be useful for identifying irregular patterns. Similarly, understanding differences in computed coverage levels that result from changes in target population estimates can be important. Methods: Using data reported annually by national immunization programmes to WHO and UNICEF, we compared the national number of births and surviving infants with estimates reported by the United Nations Population Division (UNPD). We also re-computed and compared coverage levels for the third dose of DTP containing vaccine (DTP3) using the nationally reported number of children vaccinated with DTP3 (the numerator) and the nationally reported number of children in the target population (the denominator) and compared this value with DTP3 coverage computed using the nationally reported number of children vaccinated and the UNPD estimate of the national number of surviving infants as an independent denominator. Results: We observed differences in the number of births and surviving infants reported by national immunization programmes compared with those estimated by the UNPD. Year-to-year changes in the number of births and surviving infants reported by national immunization programmes often exceeded those estimated by the UNPD. The re-computed administrative coverage levels for DTP3 using a nationally reported target population tended to be higher on average than those re-computed using the UNPD target population estimates. Conclusion: Target population estimates are a challenge for immunization programmes, and comparison to independent sources can be useful. There is increasing need to trace and better understand the processes and conditions affecting the enumeration and recording of the number of children in the target population for immunization services and the number of children vaccinated while recognizing that the challenge to do so is greater in some locations than others.

Proportionate Target Population Estimates Used by National Immunization Programmes in Sub-Saharan Africa and Comparison with Values from an External Source

Background: In order to effectively plan the delivery of immunization services, manage stock and supply levels and target interventions, national immunization programmes (NIP) must have an estimate of the target population they serve. To overcome challenges with target population estimation, some NIPs apply “rule-of-thumb” conversion factors to total population estimates. We compare these proportionate target population values with those from an external source. Methods: Using data reported by national immunization programmes in sub-Saharan Africa, we computed the proportionate target population as the number of births, surviving infants and children under 5 years of age, respectively, as a proportion of the total population size. We compared these values with those estimates computed from United Nations Population Division (UNPD) data. We then recomputed NIP target population sizes using the proportionate target population values from the UNPD applied to the total population size reported by NIP. Results: Data were available from 47 sub-Saharan Africa countries. Births as a proportion of the total population were greater within reports from NIP (median, 0.0400; IQR: 0.350 - 0.0437) compared to values from UNPD estimates (median, 0.0364; IQR: 0.0332 - 0.0406). Similar patterns were observed for surviving infants (median: NIP, 0.0360; UNPD, 0.0337) and children under 5 years of age (median: NIP, 0.1735; UNPD, 0.1594). The percent difference in proportionate target population ratios between reports from NIPs and the UNPD was >10% in 23 countries for births, in 18 countries for surviving infants, in 15 countries for children under 5 years of age. After re-computing target populations using UNPD proportionate target population values applied to NIP reported total population, recomputed administrative coverage levels for the third dose of DTP containing vaccine were higher in 32 of the 47 countries compared to reported administrative coverage levels. Conclusion: Because childhood immunization-related target populations are among the more difficult ones to accurately estimate and project, immunization programmes in sub-Saharan Africa are encouraged to include a critical assessment of the target population values, in conjunction with their national statistics system, as part of the on-going programme monitoring process.

Effectiveness of vaccination with the pentavalent rotavirus vaccine in Nicaragua as determined using the screening method

The screening method is a surveillance tool to evaluate vaccine effectiveness (VE) using coverage data on cases and available administrative estimates of vaccine coverage in the population. The aim of this analysis was to evaluate the utility and limitations of using the screening methodology to estimate VE, particularly in a developing world country with a high coverage rate, and to compare it with the VE estimates from 2 case-control studies. Using data from 2008, the screening method employed in this study estimated that VE for 3 doses of RV5 among children < 12 mo of age to prevent wild-type severe disease, resulting in hospitalization or emergency department visits, was 92% (95% confidence interval [CI]: 78–100%). Additional sensitivity analysis demonstrated that the point estimates of VE against severe disease ranged from 72% (95% CI: 62–83%) to 92% (95% CI: 78–100%); this range of VE estimates, although wide, is relatively consistent with results reported from 2 case-control studies in Nicaragua for the same time period. When the infrastructure is in place to collect reasonably robust case data, the use of the screening method to estimate VE is possible in the developing world setting. Cases of severe wild-type rotavirus gastroenteritis were obtained through an observational, hospital-based, prospective, surveillance program to assess rotavirus acute gastroenteritis. The proportion of cases vaccinated was estimated using the child’s vaccination card or health record. The proportion of the population vaccinated was estimated using administrative population-based vaccination coverage estimates provided by the Nicaraguan Ministry of Health.

Overestimation of Vitamin A Supplementation Coverage from District Tally Sheets Demonstrates Importance of Population-Based Surveys for Program Improvement: Lessons from Tanzania

BackgroundTanzania has conducted a national twice-yearly Vitamin A supplementation (VAS) campaign since 2001. Administrative coverage rates based on tally sheets consistently report >90% coverage; however the accuracy of these rates are uncertain due to potential errors in tally sheets and their aggregation, incomplete or inaccurate reporting from distribution sites, and underestimating the target population.ObjectivesThe post event coverage survey in Mainland Tanzania sought to validate tally-sheet based national coverage estimates of VAS and deworming for the June 2010 mass distribution round, and to characterize children missed by the national campaign.MethodsWHO/EPI randomized cross-sectional cluster sampling methodology was adapted for this study, using 30 clusters by 40 individuals (n = 1200), in addition to key informant interviews. Households with children 6–59 months of age were included in the study (12–59 months for deworming analysis). Chi-squared tests and logistic regression analysis were used to test differences between children reached and not reached by VAS. Data was collected within six weeks of the June 2010 round.ResultsA total of 1203 children, 58 health workers, 30 village leaders and 45 community health workers were sampled. Preschool VAS coverage was 65% (95% CI: 62.7–68.1), approximately 30% lower than tally-sheet coverage estimates. Factors associated with not receiving VAS were urban residence [OR = 3.31; p = 0.01], caretakers who did not hear about the campaign [OR = 48.7; p<0.001], and Muslim households [OR<3.25; p<0.01]. There were no significant differences in VAS coverage by child sex or age, or maternal age or education.ConclusionCoverage estimation for vitamin A supplementation programs is one of most powerful indicators of program success. National VAS coverage based on a tally-sheet system overestimated VAS coverage by ∼30%. There is a need for representative population-based coverage surveys to complement and validate tally-sheet estimates.

Yellow fever vaccination coverage following massive emergency immunization campaigns in rural Uganda, May 2011: a community cluster survey

BackgroundFollowing an outbreak of yellow fever in northern Uganda in December 2010, Ministry of Health conducted a massive emergency vaccination campaign in January 2011. The reported vaccination coverage in Pader District was 75.9%. Administrative coverage though timely, is affected by incorrect population estimates and over or under reporting of vaccination doses administered. This paper presents the validated yellow fever vaccination coverage following massive emergency immunization campaigns in Pader district.MethodsA cross sectional cluster survey was carried out in May 2011 among communities in Pader district and 680 respondents were indentified using the modified World Health Organization (WHO) 40 × 17 cluster survey sampling methodology. Respondents were aged nine months and above. Interviewer administered questionnaires were used to collect data on demographic characteristics, vaccination status and reasons for none vaccination. Vaccination status was assessed using self reports and vaccination card evidence. Our main outcomes were measures of yellow fever vaccination coverage in each age-specific stratum, overall, and disaggregated by age and sex, adjusting for the clustered design and the size of the population in each stratum.ResultsOf the 680 survey respondents, 654 (96.1%, 95% CI 94.9 – 97.8) reported being vaccinated during the last campaign but only 353 (51.6%, 95% CI 47.2 – 56.1) had valid yellow fever vaccination cards. Of the 280 children below 5 years, 269 (96.1%, 95% CI 93.7 – 98.7) were vaccinated and nearly all males 299 (96.9%, 95% CI 94.3 – 99.5) were vaccinated. The main reasons for none vaccination were; having travelled out of Pader district during the campaign period (40.0%), lack of transport to immunization posts (28.0%) and, sickness at the time of vaccination (16.0%).ConclusionsOur results show that actual yellow fever vaccination coverage was high and satisfactory in Pader district since it was above the desired minimum threshold coverage of 80% according to World Health Organization. Massive emergency vaccination done following an outbreak of Yellow fever achieved high population coverage in Pader district. Active surveillance is necessary for early detection of yellow fever cases.

Monitoring of Mass Distribution Interventions for Trachoma in Plateau State, Nigeria

Mass drug administration (MDA) with antibiotics is a key component of the SAFE strategy for trachoma control. Guidelines recommend that where MDA is warranted the whole population be targeted with 80% considered the minimum acceptable coverage. In other countries, MDA is usually conducted by salaried Ministry of Health personnel (MOH). In Plateau State, Nigeria, the existing network of volunteer Community Directed Distributors (CDD) was used for the first trachoma MDA. We conducted a population-based cluster random survey (CRS) of MDA participation to determine the true coverage and compared this to coverage reported from CDD registers. We surveyed 1,791 people from 352 randomly selected households in 24 clusters in three districts in Plateau State in January 2011, following the implementation of MDA. Households were enumerated and all individuals present were asked about MDA participation. Household heads were questioned about household-level characteristics and predictors of participation. Individual responses were compared with the CDD registers. MDA coverage was estimated as 60.3% (95% CI 47.9–73.8%) by the survey compared with 75.8% from administrative program reports. CDD registration books for comparison with responses were available in 19 of the 24 clusters; there was a match for 658/682 (96%) of verifiable responses. CDD registers did not list 481 (41.3%) of the individuals surveyed. Gender and age were not associated with individual participation. Overall MDA coverage was lower than the minimum 80% target. The observed discrepancy between the administrative coverage estimate from program reports and the CRS was largely due to identification of communities missed by the MDA and not reported in the registers. CRS for evaluation of MDA provides a useful additional monitoring tool to CDD registers. These data support modification of distributor training and MDA delivery to increase coverage in subsequent rounds of MDA.

Uptake of oral rotavirus vaccine and timeliness of routine immunization in Brazil's National Immunization Program

IntroductionIn March, 2006, oral rotavirus vaccine was added to Brazil's infant immunization schedule with recommended upper age limits for initiating (by age 14 weeks) and completing (by age 24 weeks) the two-dose series to minimize age-specific risk of intussusception following rotavirus vaccination. Several years after introduction, estimated coverage with rotavirus vaccine (83%) was lower compared to coverage for other recommended childhood immunizations (≥94%). MethodsWe analyzed data from Brazil's national immunization program on uptake of oral rotavirus vaccine by geographic region and compared administrative coverage estimates for first and second doses of oral rotavirus vaccine (Rota1 and Rota2) with first and second doses of diphtheria-tetanus-pertussis-Haemophilus influenzae type b vaccine (DTP-Hib1 and DTP-Hib2). For 27 Brazilian cities, we compared differences between estimated rotavirus and DTP-Hib coverage in 2010 with delayed receipt of DTP-Hib vaccine among a cohort of children surveyed before rotavirus introduction. ResultsIn 2010, infant vaccination coverage was 99.0% for DTP-Hib1 versus 95.2% for Rota1 (3.8% difference), and 98.4% for DTP-Hib2 versus 83.0% for Rota2 (15.4% difference), with substantial regional variation. Differences between DTP-Hib and rotavirus vaccination coverage in Brazilian cities correlated with delay in DTP-Hib vaccination among children surveyed. Age restrictions for initiating and completing the rotavirus vaccination series likely contributed to lower coverage with rotavirus vaccine in Brazil. ConclusionTo maximize benefits of rotavirus vaccination, strategies are needed to improve timeliness of routine immunizations; monitoring rotavirus vaccine uptake and intussusception risk is needed to guide further recommendations for rotavirus vaccination.

Expanding and improving urban outreach immunization in Patna, India

We conducted a case study of an urban immunization outreach strategy to determine the feasibility of the intervention and to measure administrative immunization coverage outcomes. A multipronged strategy for improving immunization coverage in Urban Patna, India, was implemented for 1 year (2009/2010). The strategy was designed to increase immunization sites, shift human resources, plan logistics, improve community mobilization, provide supervision, strengthen data flow and implement special vaccination drives. Over 1 year, the coverage of all primary vaccines of the Universal Immunization Program improved by over 100%. Coverage can be rapidly improved through outreach immunization in low socioeconomic areas if existing opportunities are carefully utilized.

Measuring the Performance of Vaccination Programs Using Cross-Sectional Surveys: A Likelihood Framework and Retrospective Analysis

The performance of routine and supplemental immunization activities is usually measured by the administrative method: dividing the number of doses distributed by the size of the target population. This method leads to coverage estimates that are sometimes impossible (e.g., vaccination of 102% of the target population), and are generally inconsistent with the proportion found to be vaccinated in Demographic and Health Surveys (DHS). We describe a method that estimates the fraction of the population accessible to vaccination activities, as well as within-campaign inefficiencies, thus providing a consistent estimate of vaccination coverage. We developed a likelihood framework for estimating the effective coverage of vaccination programs using cross-sectional surveys of vaccine coverage combined with administrative data. We applied our method to measles vaccination in three African countries: Ghana, Madagascar, and Sierra Leone, using data from each country's most recent DHS survey and administrative coverage data reported to the World Health Organization. We estimate that 93% (95% CI: 91, 94) of the population in Ghana was ever covered by any measles vaccination activity, 77% (95% CI: 78, 81) in Madagascar, and 69% (95% CI: 67, 70) in Sierra Leone. "Within-activity" inefficiencies were estimated to be low in Ghana, and higher in Sierra Leone and Madagascar. Our model successfully fits age-specific vaccination coverage levels seen in DHS data, which differ markedly from those predicted by naïve extrapolation from country-reported and World Health Organization-adjusted vaccination coverage. Combining administrative data with survey data substantially improves estimates of vaccination coverage. Estimates of the inefficiency of past vaccination activities and the proportion not covered by any activity allow us to more accurately predict the results of future activities and provide insight into the ways in which vaccination programs are failing to meet their goals. Please see later in the article for the Editors' Summary.

Progress in Measles Mortality Reduction in Ethiopia, 2002–2009

In 2002, Ethiopia adopted the African regional accelerated measles control strategies to reduce measles mortality. Routine measles vaccination is provided for infants at 9 months of age. A second opportunity for measles vaccination through supplementary immunization activities (SIAs) started in 2002, targeting children aged 6 months-14 years; periodic follow-up SIAs were conducted, targeting children aged 6-59 months from 2005 through 2009. The administrative coverage data for routine measles vaccination and the respective World Health Organization-United Nations Children's Fund vaccination coverage estimates, as well as administrative coverage during measles SIAs and the measles case-based surveillance data from 2004 through 2009, were reviewed and analyzed. The administrative coverage with routine measles vaccination increased from 37% in 2000 to 76% in 2009. The SIAs coverage was 92% for the catch-up SIAs, 88% for the first follow-up SIAs, and 92% for the second follow-up SIAs. Measles case-based surveillance met the targets set for the 2 main performance indicators during 2005-2009. Following the adoption of the measles control strategies, a reduction in the number of reported measles cases and measles outbreaks was documented. However, measles outbreaks continued to occur in Ethiopia, mainly because of suboptimal measles vaccination coverage.

Brazilian experience with rapid monitoring of vaccination coverage during a national rubella elimination campaign.

To describe an adapted version of the Pan American Health Organization (PAHO) methodology for rapid monitoring of vaccination coverage and its use as a supervisory tool to guide decision-making and strategies for end-stage vaccination activities ("mop-up" operations) following a six-week national rubella elimination campaign in Brazil. Vaccination coverage assessments modeled on a variation of PAHO's rapid house-to-house coverage monitoring methodology were conducted by Brazilian municipalities following mass immunization of adults and adolescents from August to December 2008. Results of monitoring assessments conducted in 3 658 (65.7%) of 5 564 municipalities were reported to Brazil's National Immunization Program. Information on vaccination against rubella was obtained from more than 1.5 million Brazilians (2.1% of the 70.1 million people targeted for immunization) during vaccination coverage monitoring. According to the assessment data, vaccination targets of 95% coverage were reached in 2 175 (59.5%) of the 3 658 municipalities that reported results. The percentage of municipalities that reached coverage targets was lower than administrative coverage estimates (number of vaccine doses administered divided by the immunization target population). These results informed targeted "mop-up" campaigns to reach unvaccinated populations. Rapid coverage monitoring implemented at the local level proved useful for deciding when to conclude vaccination activities and where to focus additional efforts to achieve desired coverage.

Motivational Interviewing Training at a State Psychiatric Hospital

Motivational Interviewing Training at a State Psychiatric Hospital

Cluster‐sample surveys and lot quality assurance sampling to evaluate yellow fever immunisation coverage following a national campaign, Bolivia, 2007

To estimate the yellow fever (YF) vaccine coverage for the endemic and non-endemic areas of Bolivia and to determine whether selected districts had acceptable levels of coverage (>70%). We conducted two surveys of 600 individuals (25 x 12 clusters) to estimate coverage in the endemic and non-endemic areas. We assessed 11 districts using lot quality assurance sampling (LQAS). The lot (district) sample was 35 individuals with six as decision value (alpha error 6% if true coverage 70%; beta error 6% if true coverage 90%). To increase feasibility, we divided the lots into five clusters of seven individuals; to investigate the effect of clustering, we calculated alpha and beta by conducting simulations where each cluster's true coverage was sampled from a normal distribution with a mean of 70% or 90% and standard deviations of 5% or 10%. Estimated coverage was 84.3% (95% CI: 78.9-89.7) in endemic areas, 86.8% (82.5-91.0) in non-endemic and 86.0% (82.8-89.1) nationally. LQAS showed that four lots had unacceptable coverage levels. In six lots, results were inconsistent with the estimated administrative coverage. The simulations suggested that the effect of clustering the lots is unlikely to have significantly increased the risk of making incorrect accept/reject decisions. Estimated YF coverage was high. Discrepancies between administrative coverage and LQAS results may be due to incorrect population data. Even allowing for clustering in LQAS, the statistical errors would remain low. Catch-up campaigns are recommended in districts with unacceptable coverage.

Critical Review of Literature on the Factors Pertaining to Financial Sustainability of Social Security Schemes

The sustained generation of sufficient funds to cater for pension benefits and other social security needs of retirees remains the principal challenge to the financial viability of social security schemes in most countries today. This has particularly been exacerbated by the sharp increase in the aging population requiring social security support relative to the ratio of those workers contributing to the pension fund. It has lead to the deterioration of the financial position of public retirement programs and thus putting the social security schemes under severe pressure and creating uncertainty on their future. Literature reviewed on financial sustainability of social security schemes indicates that in both developed countries and emerging market economies (EME), the financial challenges facing social security schemes are mainly due to inadequate regulatory capacity, imprudent investment, poor corporate governance and macroeconomic instability. In addition high overheads and administrative costs, limited coverage and design oversights particularly the structuring of the schemes either as pay as you go (PAYG), funded, defined contribution or defined benefit systems. Studies in this area have however, not weighed and ranked these factors on the basis of their significance to financial sustainability of the respective social security schemes they examined. Analysis undertaken in this paper shows that troubled social security schemes require a combination of measures to address the issues that undermine their financial position and sustainability. This include initiating parametric reforms, introduction of a multi-pillar pension system, implementation of good corporate governance and investment practices, reforming the regulatory and institutional framework and instituting various pension and economic reforms among others. It is important to note that nearly all studies on social security issues were carried out in developed countries. The paper nevertheless, shows that minimal research has been undertaken in this field in most developing countries. Research in this critical area of finance will therefore help expand the knowledge base in the field, especially in African countries and provide a basis for comparison with work done in other countries in addition to contributing to improved policy formulation and management.

SCHIP's Administrative Changes Could Effectively Cut Coverage

SCHIP's Administrative Changes Could Effectively Cut Coverage