Nationwide Introduction Research Articles

Die Gew\xe4hrleistung von Krankheitshilfen bei asylsuchenden Menschen: Zweiklassenmedizin in Deutschland?

ZusammenfassungHintergrundEs gibt im Bereich des Asylbewerberleistungsgesetzes (AsylbLG) zwei Möglichkeiten der Leistungsgewährung mit praktischer Relevanz für die Gesundheitsversorgung (abhängig von der Voraufenthaltszeit): die Grundleistungen und die Leistungen in besonderen Fällen analog zum Sozialgesetzbuch (SGB) XII.MethodikDie Sekundärdatenanalyse untersucht das Leistungsgeschehen im Krankheitsfall bei den Leistungsempfängern nach dem AsylbLG beim Forschungsdatenzentrum der Statistischen Ämter des Bundes und der Länder. Dem untersuchten Personenkreis wurde noch keine Flüchtlingseigenschaft bzw. Asylberechtigung zuerkannt.ErgebnisseZum Stichtag 31.12.2018 bezogen 423.201 Personen in Deutschland Leistungen nach dem AsylbLG. Davon war gut ein Drittel Frauen. Das Durchschnittsalter betrug 24 Jahre. Über die Hälfte stammte aus Asien. Über ein Drittel aller Leistungsempfänger befand sich in ambulanter (33,5 %) oder stationärer Behandlung (1,3 %). Zwischen den Bundesländern variierten die Leistungen zur Hilfe bei Krankheit sowie die gesundheitsbezogenen Pro-Kopf-Bruttoausgaben sehr stark. Die Gewährung von Leistungen bei Krankheit war in Aufnahmeeinrichtungen relativ gering. Mit Gesundheitskarte war die Inanspruchnahme stationärer Behandlung generell höher.Die gesundheitsbezogene Regelversorgung mit Hilfen in besonderen Fällen (§2 AsylbLG analog SGB XII) erreichte einen größeren Anteil an leistungsberechtigten Menschen mit 42,7 % am Jahresende als die Minimalversorgung nach §3 AsylbLG mit 29,0 %. Sie verursachte trotzdem im Vergleich weniger Bruttoausgaben.SchlussfolgerungEs wird empfohlen, §2 AsylbLG schon bei einer Voraufenthaltszeit ab 3 Monaten anzuwenden, um frühzeitiger die Hilfen analog Kap. 5–9 SGB XII gewähren zu können. Eine flächendeckende Einführung der Gesundheitskarte würde den Zugang verbessern.

TELLING STORIES ABOUT COMPREHENSIVE EDUCATION: HIDDEN HISTORIES OF POLITICS, POLICY AND PRACTICE IN POST-WAR ENGLAND

ABSTRACT This article re-visits contestation and critique over the nationwide introduction of comprehensive secondary schools in post-war England. In so doing, it considers the contribution of scholar-activist Caroline Benn (1926–2000) and a network of progressive educators who were challenging ideas about fixed ability or potential and aspiring to build a better, more inclusive education system fit for the times. The recent availability of Benn’s personal papers opens an opportunity for a deeper understanding of the politics of comprehensive education, to consider the meaning and significance of the policy as our historical perspective lengthens, notably the question of whether legislation was needed to implement so major a reform and foster cultural change in a society characterized by substantial inequalities in income, status and power. It will be argued that we need to challenge contemporary political narratives that seek to normalize academic selection as a force for social justice and high attainment and maintain a belief in the myth of meritocracy.

The Acceptability of Task-Shifting from Doctors to Allied Health Professionals.

The shifting of medical tasks (MT) to Qualified Medical Practice Assistants (MPA) is an option that can be pursued to ensure adequate health care in Germany despite the increasing scarcity of physicians. The goal of this study was to determine the acceptability of medical task-shifting to MPA among the general population. In a nationwide, representative telephone survey, 6105 persons aged 18 or older were asked whether they would be willing to receive care from a specially trained MPA at a physician's office. Their responses were tested for correlations with sociodemographic characteristics by means of bivariate (chi-squared test, Mann-Whitney U test) and multivariable statistics (logistic regression). Of the respondents, 67.2% expressed willingness to accept the shifting of MT to an MPA for the treatment of a minor illness, and 51.8% for a chronic illness. Rejection of task-shifting was associated with old age, residence in western Germany, and citizenship of a country other than Germany. For example, non-Germans rejected task-shifting more commonly than Germans, for both minor illnesses (odds ratio [OR] 2.96; 95% confidence interval [2.28; 3.85]) and chronic illnesses (OR 1.61; [1.24; 2.10]). Further studies are needed to investigate the motives for rejection of medical task-shifting to MPA in order to assess the likelihood of successful nationwide introduction of a uniform delegation model.

Persistent and Emerging Pneumococcal Carriage Serotypes in a Rural Gambian Community After 10 Years of Pneumococcal Conjugate Vaccine Pressure.

The continuing impact of pneumococcal conjugate vaccines (PCVs) in regions with high pneumococcal transmission is threatened by the persistence of vaccine serotypes (VTs) and the emergence of nonvaccine serotypes (NVTs). In 2016, we conducted a cross-sectional carriage survey (CSS5) in a community where PCV7 was first introduced in 2006 during a cluster-randomized trial conducted before nationwide introduction of PCV7 (2009) and PCV13 (2011). We estimated prevalence of PCV13 VT and NVT by age and compared these with earlier surveys before (CSS0), during (CSS1-3), and after the trial but before PCV13 (CSS4). Genomic analysis was conducted for the nontypeable pneumococci. Prevalence of PCV13 VT carriage decreased during the 10 years between CSS0 and CSS5 across all age groups (67.6% to 13.5%, P < .001; 59.8% to 14.4%, P < .001; 43.1% to 17.9%, P < .001; and 24.0% to 5.1%, P < .001, in <2, 2-4, 5-14, and ≥15 years, respectively). However, there was no difference between CSS4 and CSS5 in children ≥2 years and adults (children <2 years, no data). The prevalence of PCV13 NVT increased between CSS0 and CSS5 for children <2 years but decreased in older children and adults. In CSS5, serotypes 3, 6A, and 19F were the most common VT and nontypeable isolates were the most common NVT. Among nontypeable isolates, 73.0% lost the ability to express a capsule. Of these, 70.8% were from a VT background. The decrease in PCV13 VT that has occurred since the introduction of PCV13 appears to have plateaued. Significant carriage of these serotypes remains in all age groups.

Evaluation of pneumococcal meningitis clusters in Burkina Faso and implications for potential reactive vaccination

BackgroundTo better understand how to prevent and respond to pneumococcal meningitis outbreaks in the meningitis belt, we retrospectively examined Burkina Faso’s case-based meningitis surveillance data for pneumococcal meningitis clusters and assessed potential usefulness of response strategies. MethodsDemographic and clinical information, and cerebrospinal fluid laboratory results for meningitis cases were collected through nationwide surveillance. Pneumococcal cases were confirmed by culture, polymerase chain reaction (PCR), or latex agglutination; strains were serotyped using PCR. We reviewed data from 2011 to 2017 to identify and describe clusters of ≥ 5 confirmed pneumococcal meningitis cases per week in a single district. We assessed whether identified clusters met the 2016 WHO provisional pneumococcal meningitis outbreak definition: a district with a weekly incidence of >5 suspected meningitis cases/100,000 persons, >60% of confirmed meningitis cases caused by Streptococcus pneumoniae, and >10 confirmed pneumococcal meningitis cases. ResultsTwenty pneumococcal meningitis clusters were identified, with a maximum weekly incidence of 7 cases and a maximum duration of 4 weeks. Most identified clusters (15/20; 75%) occurred before nationwide introduction of 13-valent pneumococcal conjugate vaccine (PCV13) in October 2013. Most cases were due to serotype 1 (74%), 10% were due to PCV13 serotypes besides serotype 1, and 8 clusters had >1 serotype. While 6 identified clusters had a weekly incidence of >5 suspected cases/100,000 and all 20 clusters had >60% of confirmed meningitis cases due to S. pneumoniae, no cluster had >10 confirmed pneumococcal meningitis cases in a single week. ConclusionsFollowing PCV13 introduction, pneumococcal meningitis clusters were rarely detected, and none met the WHO provisional pneumococcal outbreak definition. Due to the limited cluster size and duration, there were no clear instances where reactive vaccination could have been useful. More data are needed to inform potential response strategies.

Nationwide introduction of a new competency framework for undergraduate medical curricula: a collaborative approach.

Switzerland recently introduced PROFILES, a revised version of its national outcomes reference framework for the undergraduate medical curriculum. PROFILES is based on a set of competencies adapted from the CanMEDS framework and nine entrustable professional activities (EPAs) that students have to be able to perform autonomously in the context of a predefined list of clinical situations. The nationwide implementation of such a competency- and EPA-based approach to medical education is a complex process that represents an important change to the organisation of undergraduate training in the various medical schools. At the same time, the concepts underlying PROFILES also have to be reflected at the level of the Federal Licencing Examination (FLE) and the national accreditation process. The vice-deans for education mandated a Swiss Working Group for PROFILES Implementation (SWGPI) to elaborate a guide presenting the principles and best practices based on the current scientific literature, to ensure the coherence between the future developments of the medical curricula and the evolution of the FLE, and to propose a coordinated research agenda to evaluate the implementation process. On the basis of the literature and analysis of our national context, we determined the key elements important for a successful implementation. They can be grouped into several areas including curricular design and governance, the assessment system and entrustment process, faculty development and change management. We also identified two dimensions that will be of particular importance to create synergies and facilitate exchange between the medical schools: a systematic approach to curriculum mapping and the longitudinal integration of an e-portfolio to support the student learning process. The nationwide collaborative approach to define strategies and conditions for the implementation of a new reference framework has allowed to develop a shared understanding of the implications of PROFILES, to promote the establishment of Swiss mapping and e-portfolio communities, and to establish the conditions necessary for ensuring the continuous alignment of the FLE with the evolving medical curricula.

Nationwide introduction of a new competency framework for undergraduate medical curricula: a collaborative approach.

Switzerland recently introduced PROFILES, a revised version of its national outcomes reference framework for the undergraduate medical curriculum. PROFILES is based on a set of competencies adapted from the CanMEDS framework and nine entrustable professional activities (EPAs) that students have to be able to perform autonomously in the context of a predefined list of clinical situations. The nationwide implementation of such a competency- and EPA-based approach to medical education is a complex process that represents an important change to the organisation of undergraduate training in the various medical schools. At the same time, the concepts underlying PROFILES also have to be reflected at the level of the Federal Licencing Examination (FLE) and the national accreditation process. The vice-deans for education mandated a Swiss Working Group for PROFILES Implementation (SWGPI) to elaborate a guide presenting the principles and best practices based on the current scientific literature, to ensure the coherence between the future developments of the medical curricula and the evolution of the FLE, and to propose a coordinated research agenda to evaluate the implementation process. On the basis of the literature and analysis of our national context, we determined the key elements important for a successful implementation. They can be grouped into several areas including curricular design and governance, the assessment system and entrustment process, faculty development and change management. We also identified two dimensions that will be of particular importance to create synergies and facilitate exchange between the medical schools: a systematic approach to curriculum mapping and the longitudinal integration of an e-portfolio to support the student learning process. The nationwide collaborative approach to define strategies and conditions for the implementation of a new reference framework has allowed to develop a shared understanding of the implications of PROFILES, to promote the establishment of Swiss mapping and e-portfolio communities, and to establish the conditions necessary for ensuring the continuous alignment of the FLE with the evolving medical curricula.

Does the German Minimum Wage Help Low Income Households?: Evidence from Observed Outcomes and the Simulation of Potential Effects

This study provides ex-post evidence on the redistributive impact of the minimum wage on disposable household incomes in Germany. Although the reduction of income inequality and poverty were emphasized as policy goals of the of minimum wage introduction, the distributional literature for Germany has focused on hourly wages and earnings or relied on ex-ante simulations. Since ‘natural’ control groups are not available due to a nationwide introduction, this paper accumulates descriptive evidence. Based on data from the German Socio-Economic Panel we analyze changes in wage and income inequality, poverty, and different mechanisms that affect transmission from individual gross wage-rates to disposable household incomes. The minimum wage is found to be an ineffective tool for income redistribution. Increases at the bottom of the wage distribution do not translate into increases in disposable incomes of poor households because individuals affected by the minimum wage do not live primarily in households at the bottom, but are spread across the income distribution. Thus, welfare dependence is only marginally reduced. Additional simulations show that neither full compliance, nor substantial increases of the level would make the minimum wage more effective in reducing inequality and poverty.

Long term resource consequences of a nationwide introduction of robotic surgery for women with early stage endometrial cancer

ObjectiveThe majority of cost-studies related to robotic surgery has a short follow-up and primarily report the costs from the index surgery. The aim of this study was to evaluate the long-term resource consequences of introducing robotic surgery for early stage endometrial cancer in Denmark. MethodsThe study included all women with early stage endometrial cancer who underwent robotic, laparoscopic and open access surgery from January 2008 to June 2015. Data was linked from national databases to determine resource consumption and costs from hospital treatments, outpatient contacts, primary health care sector visits, labor market affiliation and prescription of medication. Each patient was observed in a period of 12 months before- and after surgery. The key exposure variable was women who were exposed to robotic surgery compared to those who were not. ResultsA total of 4133 women underwent surgery for early stage endometrial cancer. The study found additional costs of $7309 (95% confidence interval [CI] 2100–11,620, P = 0.001) per patient in the group exposed to robotic surgery including long-term costs post-surgery compared to the non-exposed group (non-robotic group). When controlling for time trends, the introduction of robotic surgery did not reduce the number of bed days (mean diff −0.42, 95% CI −3.03–2.19, P = 0.752). ConclusionsThe introduction of robotic surgery for early stage endometrial cancer did not generate any long-term cost savings. The additional costs of robotic surgery were primarily driven by the index surgery. Any reduction in bed days could be explained by time trends.

Nationwide Introduction of Minimally Invasive Robotic Surgery for Early-Stage Endometrial Cancer and Its Association With Severe Complications

ImportanceMinimally invasive laparoscopic surgery (MILS) for endometrial cancer reduces surgical morbidity compared with a total abdominal hysterectomy. However, only a minority of women with early-stage endometrial cancer undergo MILS.ObjectiveTo evaluate the association between the Danish nationwide introduction of minimally invasive robotic surgery (MIRS) and severe complications in patients with early-stage endometrial cancer.Design, Setting, and ParticipantsIn this nationwide prospective cohort study of 5654 women with early-stage endometrial cancer who had undergone surgery during the period from January 1, 2005, to June 30, 2015, data from the Danish Gynecological Cancer Database were linked with national registers on socioeconomic status, deaths, hospital diagnoses, and hospital treatments. The women were divided into 2 groups; group 1 underwent surgery before the introduction of MIRS in their region, and group 2 underwent surgery after the introduction of MIRS. Women with an unknown disease stage, an unknown association with MIRS implementation, unknown histologic findings, sarcoma, or synchronous cancer were excluded, as were women who underwent vaginal or an unknown surgical type of hysterectomy. Statistical analysis was conducted from February 2, 2017, to May 4, 2018.ExposureMinimally invasive robotic surgery, MILS, or total abdominal hysterectomy.Main Outcomes and MeasuresSevere complications were dichotomized and encompassed death within 30 days after surgery and intraoperative and postoperative complications diagnosed within 90 days after surgery.ResultsA total of 3091 women (mean [SD] age, 67 [10] years) were allocated to group 1, and a total of 2563 women (mean [SD] age, 68 [10] years) were allocated to group 2. In multivariate logistic regression analyses, the odds of severe complications were significantly higher in group 1 than in group 2 (odds ratio [OR], 1.39; 95% CI, 1.11-1.74). The proportion of women undergoing MILS was 14.1% (n = 436) in group 1 and 22.2% in group 2 (n = 569). The proportion of women undergoing MIRS in group 2 was 50.0% (n = 1282). In group 2, multivariate logistic regression analyses demonstrated that a total abdominal hysterectomy was associated with increased odds of severe complications compared with MILS (OR, 2.58; 95% CI, 1.80-3.70) and MIRS (OR, 3.87; 95% CI, 2.52-5.93). No difference was found for MILS compared with MIRS (OR, 1.50; 95% CI, 0.99-2.27).Conclusions and RelevanceThe national introduction of MIRS changed the surgical approach for early-stage endometrial cancer from open surgery to minimally invasive surgery. This change in surgical approach was associated with a significantly reduced risk of severe complications.

Impact of Rotavirus Vaccine Introduction in Children Less Than 2 Years of Age Presenting for Medical Care With Diarrhea in Rural Matlab, Bangladesh.

BackgroundFollowing the conclusion of a human rotavirus vaccine (HRV) cluster-randomized, controlled trial (CRT) in Matlab, Bangladesh, HRV was included in Matlab’s routine immunization program. We describe the population-level impact of programmatic rotavirus vaccination in Bangladesh in children <2 years of age.MethodsInterrupted time series were used to estimate the impact of HRV introduction. We used diarrheal surveillance collected between 2000 and 2014 within the 2 service delivery areas (International Centre for Diarrhoeal Disease Research, Bangladesh [icddr,b] service area [ISA] and government service area [GSA]) of the Matlab Health and Demographic Surveillance System, administered by icddr,b. Age group–specific incidence rates were calculated for both rotavirus-positive (RV+) and rotavirus-negative (RV–) diarrhea diagnoses of any severity presenting to the hospital. We used 2 models to assess the impact within each service area: Model 1 used the pre-vaccine time period in all villages (HRV– and control-only) and Model 2 combined the pre-vaccine time period and the CRT time period, using outcomes from control-only villages.ResultsBoth models demonstrated a downward trend in RV+ diarrheal incidences in the ISA villages during 3.5 years of routine HRV use, though only Model 2 was statistically significant. Significant impacts of HRV on RV+ diarrhea incidences in GSA villages were not observed in either model. Differences in population-level impacts between the 2 delivery areas may be due to the varied rotavirus vaccine coverage and presentation rates to the hospital.ConclusionsThis study provides initial evidence of the population-level impact of rotavirus vaccines in children <2 years of age in Matlab, Bangladesh. Further studies are needed of the rotavirus vaccine impact after the nationwide introduction in Bangladesh.

Survival after a nationwide introduction of robotic surgery in women with early-stage endometrial cancer: a population-based prospective cohort study

PurposeThe purpose of the study was to evaluate the association between a nationwide introduction of robotic minimally invasive surgery (RMIS) and survival in women with early-stage endometrial cancer. Materials and methodsProspective data on consecutive women with early-stage endometrial cancer who underwent surgery during January 2005 to June 2015 in Denmark were identified in the nationwide Danish Gynaecological Cancer Database. Data were linked with national registries regarding comorbidity, education, income and death. The cohort was divided according to the time they underwent surgery: Group 1 before RMIS introduction in their respective region and Group 2 after RMIS introduction. Five-year overall survival was compared by multivariate Cox proportional hazards models stratified by histopathological risk between Groups 1 and 2 and between surgical modalities within Group 2: total abdominal hysterectomy (TAH), laparoscopic minimally invasive surgery (LMIS) and RMIS. ResultsWomen in Group 1 (N = 3091) had significantly lower overall survival compared with those in Group 2 (N = 2563; hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.05–1.42). Age, smoking, socioeconomic status, American Society of Anaesthesiologists (ASA) score, comorbidity and histopathological risk influenced the overall survival. Following RMIS adoption, TAH was associated with higher mortality compared with LMIS and RMIS (HR, 1.42; 95% CI 1.02–1.97 and HR, 1.70; 95% CI 1.31–2.19 for LMIS and RMIS, respectively). There was no significant survival difference between RMIS and LMIS (HR, 1.19; 95% CI 0.85–1.68). ConclusionThe national introduction of robotic surgery for early-stage endometrial cancer was associated with improved survival irrespective of age, body mass index, ASA score, comorbidity, smoking, socioeconomic status and histopathological risk.

Az önkormányzati ASP rendszer bevezetésének és használatának tapasztalatai The experiences of the introduction and application of the Municipality ASP system

The thought of the nationwide introduction of the Municipality ASP system (hereafter: ASP) emerged in 2014 as a governmental objective. Between 2015 and 2019 - with the exception of the capital - every local government joined the ASP, which now has approximately 30.000 daily users. The main point of the ASP is that the state provides a standardized IT solution for the local governments through a remote service provider technology, in order to support different municipality functions. The novelty of the ASP is that the different management systems operate as part of an integrated system. The ASP supports the magisterial and administrational tasks of the local governments in the following areas: local tax management, financial management, estate cadaster, trade, inheritance, record management. One of the main objectives of the ASP is the widespread implementation of electronic administration. The state provides the ASP system free of charge for the local governments.

Variation in Prescription Opioid Dispensing across Neighborhoods of Diverse Socioeconomic Disadvantages in Victoria, Australia.

The study examined the relationship between dispensing patterns of prescription opioids, neighborhood-disadvantage-index, and standardized doses dispensed. Three-year’s dispensing data drawn from 80 local government areas (LGAs) within Victoria, Australia’s second most populous state, was analyzed. Quantities dispensed in defined daily dose (DDD)/1000-people/day were computed for LGAs of low, moderate, high, and very high socio-economic disadvantage. LGAs with various levels of dispensing, and neighborhood disadvantage were identified and mapped. A multivariable regression model examined the effect of neighborhood level disadvantage and identified other factors that are associated with standardized doses dispensed. More women were dispensed opioids than men. Dispensing increased with increasing age. Most of the LGAs with relatively high dispensing were socioeconomically disadvantaged and located outside the major cities. Dispensing gradually increased from low disadvantage to very high disadvantage areas. Dispensing of standardized doses were consistently higher in rural areas than in urban areas. Neighborhood level disadvantage, age, sex, and urbanization were significant factors in the standardized doses dispensed. As inappropriate dispensing of opioids is a major public health problem, research should facilitate understanding of utilization in small areas to enable tailored public health programs. Nationwide and consistent introduction of real-time prescription drug-monitoring programs, and structural interventions to reduce the fundamental causes of socioeconomic disadvantage and isolation are recommended.

Evaluation of organized cancer screening programs: general aspects and current status in Germany

In the past decades, it has been increasingly recognized that cancer screening is not always or not exclusively beneficial and, in the case of some measures, the negative effects may even outweigh the benefits. This has fundamentally changed the significance and emphasis placed on the evaluation of cancer screening programs. Generally, there is adistinction between an endpoint evaluation, which assesses the effectiveness or risk/benefit ratio, and aprocess evaluation, which aims to ensure optimum implementation of the program.Prior to the nationwide introduction of ascreening measure, proof of effectiveness should ideally be provided by arandomized controlled trial (RCT), in which persons without ascreening offer form the control group. From ascientific point of view, this study design is by far the best method to evaluate the endpoint, as it avoids biases that may distort the results in observational studies. RCT evidence on cancer screening measures currently offered by statutory health insurance providers in Germany - if available at all - originates exclusively from other countries.When mammography screening was introduced as the first organized screening program in Germany, comprehensive measures for process evaluation were taken. In April 2013, the legal basis for the transfer of colorectal and cervical cancer screening into organized programs was created. According to the legal provisions, both aprocess and an endpoint evaluation are planned for the new programs. It remains to be seen how the necessary data flows will be conceptualized and later implemented in practice.

Use and Assessment of E-Voting Systems: Findings from an Online-Survey among Swiss Nationals Living Abroad

Digitalization has led to an increase in electronic government services and democratic developments. One crucial aspect in the context of e-government for democracies consists of e-voting systems, which enable citizens to vote electronically. The Swiss government recently decided on the nationwide introduction of e-voting systems. One target group, which could particularly benefit from the introduction of e-voting systems, are Swiss nationals living abroad. However, the introduction of e-voting systems entails costs, thus an estimation of the willingness of Swiss nationals abroad to make use of the possibility of voting electronically is central to the introduction of e-voting systems. In November 2017, 596 Swiss citizens living abroad completed a questionnaire addressing their experience with and assessment of e-voting systems. Results yield a very high willingness to use e-voting among the respondents. Swiss nationals living abroad seem to perceive e-voting as being very useful and efficient. In addition, the findings show that concerns about data security seem to be of high importance for potential users of e-voting systems.

Child Mortality in Mozambique: a Review of Recent Trends and Attributable Causes

In the last 25 years, child mortality has significantly dropped at a global level. Understanding particularities of child mortality at the national level is useful to tailor health policy to those conditions requiring more attention. In Mozambique, a variety of efforts have been made to better characterize the overall child mortality and to describe the main contributors for death. In this review, we attempt to contextualize current knowledge on causes of pediatric deaths in Mozambique. The available data regarding the principal causes of death in Mozambican children point out to infectious diseases and neonatal causes as the principal causes of preventable deaths, with important variations in recent years in line with the epidemiological changes seen in the country as a result of reductions in malaria transmission and the impact of the nationwide introduction of different conjugate vaccines. Data regarding the main causes of death among children in Mozambique are patchy, outdated, and in many cases based on methodologies with many underlying limitations, which make them unreliable. More robust postmortem methodologies to study the underlying causes of mortality, currently being introduced in a surveillance sentinel site of the country, will surely contribute to improve our understanding of what is really killing children in this country.

Epidemiological profile and progress toward rubella elimination in China. 10 years after nationwide introduction of rubella vaccine

BackgroundRubella-containing vaccine (RCV) became available in China in 1993 and was introduced nationwide into the Expanded Immunization Program (EPI) in 2008. We evaluated implementation and impact of RCV from 2 years prior to nationwide introduction through the 10 years after nationwide introduction. MethodsWe analyzed RCV lot-release (doses distributed) data, 1- and 2-dose RCV coverage, and rubella data from China’s nationwide disease surveillance system to describe the current status and changes in rubella epidemiology between 2005 and 2017. ResultsWhile the vaccine was included into the routine immunization program in 2008, its full implementation required 4 years due to sporadic vaccine supply constraints. RCV1 and RCV2 coverage increased from 51.5% and 39.0% in 2008 to >95% during 2012 through 2016. From 2005 to 2017, the annual incidences (per million) of rubella ranged from 91.09 in 2008 down to 1.16 in 2017; reductions occurred in all age groups. The proportion of cases among individuals ≥20 years old increased from 0.97% in 2005 to 31.2% in 2017. In the better-developed eastern China, most cases were among adults; in central and western China, most cases were among children or adolescents. ConclusionsThe marked decrease rubella was a result of inclusion of RCVs into EPI targeting children less than 2 years of age and achieving high level of 2-dose coverage. Rubella was reduced in absolute terms, and its epidemiology was changed to older cases with substantial inter-province variation. Ensuring full vaccination of school children and identifying strategies to reach adults with measles and rubella combined vaccines will be important to hasten elimination of rubella and prevent CRS outbreaks.

Street‐level bureaucrats, rule‐following and tenure: How assessment tools are used at the front line of the public sector

Studies on street‐level bureaucracy examine actions of frontline workers within the public sector. In this literature, there is a lack of evidence on how job tenure affects how frontline workers respond to formal steering. We contribute to prior research by studying the nationwide introduction of an assessment support tool to be used by caseworkers to assess clients’ needs under the Swedish active labour market policy. We examine the potential effects of tenure on how caseworkers use this tool. The empirical analysis is based on quantitative and qualitative data. We show that as tenure increases, street‐level bureaucrats, especially male caseworkers, tend to act in accordance with policy signals to a lesser extent. The qualitative analysis shows that this pattern can partly be explained by the fact that increasing experience with meeting clients face to face increases caseworkers’ perceived confidence and skills.

Impact and cost-effectiveness of rotavirus vaccination in Bangladesh

IntroductionDiarrheal disease is a leading cause of child mortality globally, and rotavirus is responsible for more than a third of those deaths. Despite substantial decreases, the number of rotavirus deaths in children under five was 215,000 per year in 2013. Of these deaths, approximately 41% occurred in Asia and 3% of those in Bangladesh. While Bangladesh has yet to introduce rotavirus vaccination, the country applied for Gavi support and plans to introduce it in 2018. This analysis evaluates the impact and cost-effectiveness of rotavirus vaccination in Bangladesh and provides estimates of the costs of the vaccination program to help inform decision-makers and international partners. MethodsThis analysis used Pan American Health Organization’s TRIVAC model (version 2.0) to examine nationwide introduction of two-dose rotavirus vaccination in 2017, compared to no vaccination. Three mortality scenarios (low, high, and midpoint) were assessed. Benefits and costs were examined from the societal perspective over ten successive birth cohorts with a 3% discount rate. Model inputs were locally acquired and complemented by internationally validated estimates. ResultsOver ten years, rotavirus vaccination would prevent 4000 deaths, nearly 500,000 hospitalizations and 3 million outpatient visits in the base scenario. With a Gavi subsidy, cost/disability adjusted life year (DALY) ratios ranged from $58/DALY to $142/DALY averted. Without a Gavi subsidy and a vaccine price of $2.19 per dose, cost/DALY ratios ranged from $615/DALY to $1514/DALY averted. ConclusionThe discounted cost per DALY averted was less than the GDP per capita for nearly all scenarios considered, indicating that a routine rotavirus vaccination program is highly likely to be cost-effective. Even in a low mortality setting with no Gavi subsidy, rotavirus vaccination would be cost-effective. These estimates exclude the herd immunity benefits of vaccination, so represent a conservative estimate of the cost-effectiveness of rotavirus vaccination in Bangladesh.