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EClinicalMedicine Jul 2018HIV-infected and HIV-exposed uninfected (HEU) children have an increased risk of measles that may be due to altered immune responses or suboptimal timing of measles...
BACKGROUND
HIV-infected and HIV-exposed uninfected (HEU) children have an increased risk of measles that may be due to altered immune responses or suboptimal timing of measles vaccination. We aimed to evaluate the safety and immunogenicity of measles vaccination in HIV-infected and HEU children.
METHODS
For this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Library, CINAHL, Global Health Library and IndMED on May 9, 2018. Studies were included if they reported on safety or seroresponse (either seroprotection/seropositivity/seroconversion) after measles vaccination in HIV-infected or HEU children. We calculated pooled estimates to compare immunogenicity outcomes between HIV-infected, HEU and HIV-unexposed children, using risk ratios [RRs] (with 95%CIs). PROSPERO registration number: CRD42017057411.
FINDINGS
Seventy-one studies met the inclusion criteria (15,363 children). Twenty-eight studies reported on safety; vaccine-associated adverse events and deaths were uncommon. Sixty-two studies reported on immunogenicity, 27 were included in the meta-analysis. HIV-infected children had lower seroresponse rates after primary vaccination compared with HIV-unexposed (RR 0.74; 95%CI: 0.61-0.90, = 85.9%) and HEU children (0.78; 0.69-0.88, = 77.1%), which was mitigated by antiretroviral therapy and time interval between vaccination and serology. HEU and HIV-unexposed children had similar seroresponses. Vaccination at 6-months resulted in similar proportions of HIV-infected children having seroresponse compared with HIV-unexposed (0.96; 0.77-1.19) and HEU children (1.00; 0.73-1.37, = 63.7%).
INTERPRETATION
Primary measles vaccination at 6-months of age may provide protection against measles during early infancy in settings with high prevalence of maternal HIV-infection, however, further studies are needed to evaluate this strategy in HEU children and HIV-infected children receiving antiretroviral therapy.
FUNDING
South African Research Chairs Initiative of the Department of Science and Technology and National Research Foundation in Vaccine Preventable Diseases; Medical Research Council: Respiratory and Meningeal Pathogens Research Unit.
PubMed: 31193646
DOI: 10.1016/j.eclinm.2018.06.002 -
Acta Paediatrica (Oslo, Norway : 1992) Jul 2022Millions of Ukrainian children have been internally displaced or fled to other countries because of the Russian war. This systematic review focused on their health needs...
AIM
Millions of Ukrainian children have been internally displaced or fled to other countries because of the Russian war. This systematic review focused on their health needs and future challenges for clinicians.
METHODS
A systematic literature search of the Medline, Embase and MedRxiv databases from 1 January 2010 to 31 March 2022 identified 1628 papers on the health of Ukrainian children and 112 were relevant to this review.
RESULTS
In 2019, under-5 mortality was 8 per 1000 live births in Ukraine. Underweight and adverse childhood experiences, including child abuse, were frequent compared to other European countries, while childhood obesity seemed less common. Alcohol consumption was common in women of reproductive age, including during pregnancy, risking foetal alcohol syndrome. Neonatal screening programmes provided low coverage. Vaccine hesitancy was common and vaccination rates were low. Other concerns were measles, HIV, antibiotic resistance and multi-resistant tuberculosis. Many children are expected to suffer from psychological and physical trauma due to the war. Other healthcare challenges include low COVID-19 vaccination rates and a preference for secondary and tertiary care, rather than primary care. Many people cannot afford medication.
CONCLUSION
Ukrainian children often have poor health and host countries need to be aware of their needs.
Topics: COVID-19; COVID-19 Vaccines; Child; Child Health; Female; Humans; Infant, Newborn; Pediatric Obesity; Refugees
PubMed: 35466444
DOI: 10.1111/apa.16370 -
Clinical and Experimental Vaccine... Jul 2020Vaccines are credited with reducing or effectively eradicating a number of infectious diseases such as smallpox, measles, and diphtheria. Particularly in nations like... (Review)
Review
Vaccines are credited with reducing or effectively eradicating a number of infectious diseases such as smallpox, measles, and diphtheria. Particularly in nations like the United States, where a large number of infectious diseases were prevalent, vaccines proved to be timely interventions. The approval procedure for vaccines in the United States is regulated by the Center for Biologics Evaluation and Research. Vaccine development is often found to be demanding and requires astute knowledge and understanding of recent developments by physicians and researchers to ensure that effective vaccines are made available to the masses with minimum risk. This article aims to illustrate the regulatory scenario with regards to vaccine development and licensure in the United States with a brief look at the origin of vaccines and their regulations in the nation. Also, it details the challenges faced by the United States vaccine industry to remain relevant in today's constantly evolving world.
PubMed: 32864362
DOI: 10.7774/cevr.2020.9.2.69 -
Journal of Medical Internet Research May 2023Vaccination is the most effective strategy to prevent infectious diseases, yet vaccination coverage has not reached the target level. To promote vaccination uptake,... (Review)
Review
BACKGROUND
Vaccination is the most effective strategy to prevent infectious diseases, yet vaccination coverage has not reached the target level. To promote vaccination uptake, digital health interventions (DHIs) have been used in various vaccination programs.
OBJECTIVE
This study aimed to perform a systematic review of the cost-effectiveness analyses of DHIs for the improvement of the uptake of vaccination programs.
METHODS
A literature review was conducted in MEDLINE (Ovid), Embase (Ovid), APA PsycINFO (Ovid), Web of Science, Scopus, CINAHL Ultimate (EBSCOhost), Center for Review and Dissemination, and Institute for IEEE Xplore up to October 2022. Health economic evaluations that met the following inclusion criteria were included: (1) adult or pediatric vaccination programs; (2) interventions delivered through digital technology; (3) full-scale health economic analyses including cost-effectiveness, cost-utility, cost-benefit, or cost-consequence analyses; and (4) evaluations conducted by model-based or trial-based analyses. The quality of each included study was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).
RESULTS
The systematic review included 7 studies. Four of the cost-effectiveness studies were conducted by model-based analyses, and 3 were trial-based analyses. One study reported the additional cost per quality-adjusted life years (QALYs) gained, whereas 6 studies reported the additional cost per individual vaccinated (or return case). The vaccines targeted the human papillomavirus (HPV) vaccine, influenza vaccination, measles-mumps-rubella (MMR) vaccine, and children immunization at different ages. The DHIs were delivered by television campaign, web-based decision aid, SMS text message, telephone, and computer-generated recall letters. The studies were classified as very good (n=5) and good (n=2) qualities. One study concluded that the DHI was cost-saving, and 6 studies concluded that the DHI was cost-effective.
CONCLUSIONS
This study is the first systematic review on cost-effectiveness analyses of DHIs to improve vaccination uptake. All included studies have good to very good quality on study assessment and reported the DHIs to be cost-saving or cost-effective in the improvement of vaccination uptake.
Topics: Adult; Child; Humans; Cost-Benefit Analysis; Cost-Effectiveness Analysis; Digital Technology; Immunization; Vaccination
PubMed: 37184916
DOI: 10.2196/45493 -
The Cochrane Database of Systematic... Feb 2012Mumps, measles and rubella (MMR) are serious diseases that can lead to potentially fatal illness, disability and death. However, public debate over the safety of the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Mumps, measles and rubella (MMR) are serious diseases that can lead to potentially fatal illness, disability and death. However, public debate over the safety of the trivalent MMR vaccine and the resultant drop in vaccination coverage in several countries persists, despite its almost universal use and accepted effectiveness.
OBJECTIVES
To assess the effectiveness and adverse effects associated with the MMR vaccine in children up to 15 years of age.
SEARCH METHODS
For this update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, PubMed (July 2004 to May week 2, 2011) and Embase.com (July 2004 to May 2011).
SELECTION CRITERIA
We used comparative prospective or retrospective trials assessing the effects of the MMR vaccine compared to placebo, do nothing or a combination of measles, mumps and rubella antigens on healthy individuals up to 15 years of age.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data and assessed methodological quality of the included studies. One review author arbitrated in case of disagreement.
MAIN RESULTS
We included five randomised controlled trials (RCTs), one controlled clinical trial (CCT), 27 cohort studies, 17 case-control studies, five time-series trials, one case cross-over trial, two ecological studies, six self controlled case series studies involving in all about 14,700,000 children and assessing effectiveness and safety of MMR vaccine. Based on the available evidence, one MMR vaccine dose is at least 95% effective in preventing clinical measles and 92% effective in preventing secondary cases among household contacts.Effectiveness of at least one dose of MMR in preventing clinical mumps in children is estimated to be between 69% and 81% for the vaccine prepared with Jeryl Lynn mumps strain and between 70% and 75% for the vaccine containing the Urabe strain. Vaccination with MMR containing the Urabe strain has demonstrated to be 73% effective in preventing secondary mumps cases. Effectiveness of Jeryl Lynn containing MMR in preventing laboratory-confirmed mumps cases in children and adolescents was estimated to be between 64% to 66% for one dose and 83% to 88% for two vaccine doses. We did not identify any studies assessing the effectiveness of MMR in preventing rubella.The highest risk of association with aseptic meningitis was observed within the third week after immunisation with Urabe-containing MMR (risk ratio (RR) 14.28; 95% confidence interval (CI) from 7.93 to 25.71) and within the third (RR 22.5; 95% CI 11.8 to 42.9) or fifth (RR 15.6; 95% CI 10.3 to 24.2) weeks after immunisation with the vaccine prepared with the Leningrad-Zagreb strain. A significant risk of association with febrile seizures and MMR exposure during the two previous weeks (RR 1.10; 95% CI 1.05 to 1.15) was assessed in one large person-time cohort study involving 537,171 children aged between three months and five year of age. Increased risk of febrile seizure has also been observed in children aged between 12 to 23 months (relative incidence (RI) 4.09; 95% CI 3.1 to 5.33) and children aged 12 to 35 months (RI 5.68; 95% CI 2.31 to 13.97) within six to 11 days after exposure to MMR vaccine. An increased risk of thrombocytopenic purpura within six weeks after MMR immunisation in children aged 12 to 23 months was assessed in one case-control study (RR 6.3; 95% CI 1.3 to 30.1) and in one small self controlled case series (incidence rate ratio (IRR) 5.38; 95% CI 2.72 to 10.62). Increased risk of thrombocytopenic purpura within six weeks after MMR exposure was also assessed in one other case-control study involving 2311 children and adolescents between one month and 18 years (odds ratio (OR) 2.4; 95% CI 1.2 to 4.7). Exposure to the MMR vaccine was unlikely to be associated with autism, asthma, leukaemia, hay fever, type 1 diabetes, gait disturbance, Crohn's disease, demyelinating diseases, bacterial or viral infections.
AUTHORS' CONCLUSIONS
The design and reporting of safety outcomes in MMR vaccine studies, both pre- and post-marketing, are largely inadequate. The evidence of adverse events following immunisation with the MMR vaccine cannot be separated from its role in preventing the target diseases.
Topics: Adolescent; Age Factors; Autistic Disorder; Child; Child, Preschool; Clinical Trials as Topic; Crohn Disease; Epidemiologic Studies; Humans; Infant; Measles; Measles-Mumps-Rubella Vaccine; Mumps; Purpura, Thrombocytopenic; Rubella; Seizures, Febrile; Vaccines, Attenuated
PubMed: 22336803
DOI: 10.1002/14651858.CD004407.pub3 -
Pathogens and Global Health Mar 2017The decline of immunization rates in countries of origin of migrants and refugees, along with risky conditions during the journey to Europe, may threaten migrants'... (Review)
Review
The decline of immunization rates in countries of origin of migrants and refugees, along with risky conditions during the journey to Europe, may threaten migrants' health. We performed a systematic review of the scientific literature in order to assess the frequency of vaccine preventable diseases, and vaccination coverage among migrants and refugees in Europe. To this end, Medline and Cochrane databases were considered. After the screening and the selection process, 58 papers were included in the review. We focused on the following vaccine-preventable diseases: hepatitis B, measles, rubella, mumps, tetanus, poliomyelitis, pertussis, diphtheria, meningitis, and varicella. The results were presented as a qualitative synthesis. In summary, several studies highlighted that migrants and refugees have lower immunization rates compared to European-born individuals. Firstly, this is due to low vaccination coverage in the country of origin. Then, several problems may limit migrants' access to vaccination in Europe: (i) migrants are used to move around the continent, and many vaccines require multiple doses at regular times; (ii) information on the immunization status of migrants is often lacking; (iii) hosting countries face severe economic crises; (iv) migrants often refuse registration with medical authorities for fear of legal consequences and (v) the lack of coordination among public health authorities of neighboring countries may determine either duplications or lack of vaccine administration. Possible strategies to overcome these problems include tailoring immunization services on the specific needs of the target population, developing strong communication campaigns, developing vaccination registers, and promoting collaboration among public health authorities of European Countries.
Topics: Communicable Disease Control; Communicable Diseases; Europe; Evidence-Based Medicine; Humans; Refugees; Transients and Migrants; Vaccination
PubMed: 28165878
DOI: 10.1080/20477724.2017.1281374 -
BMC Public Health Apr 2013Most cases of rubella and congenital rubella syndrome (CRS) occur in low- and middle-income countries. The World Health Organization (WHO) has recently recommended that... (Review)
Review
BACKGROUND
Most cases of rubella and congenital rubella syndrome (CRS) occur in low- and middle-income countries. The World Health Organization (WHO) has recently recommended that countries accelerate the uptake of rubella vaccination and the GAVI Alliance is now supporting large scale measles-rubella vaccination campaigns. We performed a review of health economic evaluations of rubella and CRS to identify gaps in the evidence base and suggest possible areas of future research to support the planned global expansion of rubella vaccination and efforts towards potential rubella elimination and eradication.
METHODS
We performed a systematic search of on-line databases and identified articles published between 1970 and 2012 on costs of rubella and CRS treatment and the costs, cost-effectiveness or cost-benefit of rubella vaccination. We reviewed the studies and categorized them by the income level of the countries in which they were performed, study design, and research question answered. We analyzed their methodology, data sources, and other details. We used these data to identify gaps in the evidence and to suggest possible future areas of scientific study.
RESULTS
We identified 27 studies: 11 cost analyses, 11 cost-benefit analyses, 4 cost-effectiveness analyses, and 1 cost-utility analysis. Of these, 20 studies were conducted in high-income countries, 5 in upper-middle income countries and two in lower-middle income countries. We did not find any studies conducted in low-income countries. CRS was estimated to cost (in 2012 US$) between $4,200 and $57,000 per case annually in middle-income countries and up to $140,000 over a lifetime in high-income countries. Rubella vaccination programs, including the vaccination of health workers, children, and women had favorable cost-effectiveness, cost-utility, or cost-benefit ratios in high- and middle-income countries.
CONCLUSIONS
Treatment of CRS is costly and rubella vaccination programs are highly cost-effective. However, in order for research to support the global expansion of rubella vaccination and the drive towards rubella elimination and eradication, additional studies are required in low-income countries, to tackle methodological limitations, and to determine the most cost-effective programmatic strategies for increased rubella vaccine coverage.
Topics: Cost-Benefit Analysis; Developed Countries; Developing Countries; Female; Health Care Costs; Humans; Mass Vaccination; Pregnancy; Pregnancy Complications, Infectious; Rubella; Rubella Syndrome, Congenital; Rubella Vaccine
PubMed: 23627715
DOI: 10.1186/1471-2458-13-406 -
The Cochrane Database of Systematic... Jan 2018Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population-based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient-oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review.
OBJECTIVES
To evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2017. We also searched grey literature and trial registers to January 2017.
SELECTION CRITERIA
We included randomized trials, controlled before and after studies, and interrupted time series evaluating immunization-focused patient reminder or recall interventions in children, adolescents, and adults who receive immunizations in any setting. We included no-intervention control groups, standard practice activities that did not include immunization patient reminder or recall, media-based activities aimed at promoting immunizations, or simple practice-based awareness campaigns. We included receipt of any immunizations as eligible outcome measures, excluding special travel immunizations. We excluded patients who were hospitalized for the duration of the study period.
DATA COLLECTION AND ANALYSIS
We used the standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group. We present results for individual studies as relative rates using risk ratios, and risk differences for randomized trials, and as absolute changes in percentage points for controlled before-after studies. We present pooled results for randomized trials using the random-effects model.
MAIN RESULTS
The 75 included studies involved child, adolescent, and adult participants in outpatient, community-based, primary care, and other settings in 10 countries.Patient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (risk ratio (RR) of 1.28, 95% confidence interval (CI) 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.Three types of single-method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single-method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).Based on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non-influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).
AUTHORS' CONCLUSIONS
Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.
Topics: Adolescent; Adult; Child; Correspondence as Topic; Humans; Immunization; Immunization Programs; Randomized Controlled Trials as Topic; Reminder Systems; Telephone; Text Messaging
PubMed: 29342498
DOI: 10.1002/14651858.CD003941.pub3 -
PharmacoEconomics Oct 2020Cost-of-illness data from empirical studies provide insights into the use of healthcare resources including both expenditures and the opportunity cost related to... (Review)
Review
BACKGROUND
Cost-of-illness data from empirical studies provide insights into the use of healthcare resources including both expenditures and the opportunity cost related to receiving treatment.
OBJECTIVE
The objective of this systematic review was to gather cost data and relevant parameters for hepatitis B, pneumonia, meningitis, encephalitis caused by Japanese encephalitis, rubella, yellow fever, measles, influenza, and acute gastroenteritis in children in low- and middle-income countries.
DATA SOURCES
Peer-reviewed studies published in public health, medical, and economic journals indexed in PubMed (MEDLINE), Embase, and EconLit.
STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS
Studies must (1) be peer reviewed, (2) be published in 2000-2016, (3) provide cost data for one of the nine diseases in children aged under 5 years in low- and middle-income countries, and (4) generated from primary data collection.
LIMITATIONS
We cannot exclude missing a few articles in our review. Measures were taken to reduce this risk. Several articles published since 2016 are omitted from the systematic review results, these articles are included in the discussion.
CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS
The review yielded 37 articles and 267 sets of cost estimates. We found no cost-of-illness studies with cost estimates for hepatitis B, measles, rubella, or yellow fever from primary data. Most estimates were from countries in Gavi preparatory (28%) and accelerated (28%) transition, followed by those who are initiating self-financing (22%) and those not eligible for Gavi support (19%). Thirteen articles compared household expenses to manage illnesses with income and two articles with other household expenses, such as food, clothing, and rent. An episode of illness represented 1-75% of the household's monthly income or 10-83% of its monthly expenses. Articles that presented both household and government perspectives showed that most often governments incurred greater costs than households, including non-medical and indirect costs, across countries of all income statuses, with a few notable exceptions. Although limited for low- and middle-income country settings, cost estimates generated from primary data collection provided a 'real-world' estimate of the economic burden of vaccine-preventable diseases. Additional information on whether common situations preventing the application of official clinical guidelines (such as medication stock-outs) occurred would help reveal deficiencies in the health system. Improving the availability of cost-of-illness evidence can inform the public policy agenda about healthcare priorities and can help to operationalize the healthcare budget in local health systems to respond adequately to the burden of illness in the community.
Topics: Child; Cross-Sectional Studies; Developing Countries; Humans; Income; Prospective Studies; Retrospective Studies
PubMed: 32748334
DOI: 10.1007/s40273-020-00940-4 -
The Cochrane Database of Systematic... Jun 2016More than 7.5 million children younger than age five living in low- and middle-income countries die every year. The World Health Organization (WHO) developed the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
More than 7.5 million children younger than age five living in low- and middle-income countries die every year. The World Health Organization (WHO) developed the integrated management of childhood illness (IMCI) strategy to reduce mortality and morbidity and to improve quality of care by improving the delivery of a variety of curative and preventive medical and behavioral interventions at health facilities, at home, and in the community.
OBJECTIVES
To evaluate the effects of programs that implement the IMCI strategy in terms of death, nutritional status, quality of care, coverage with IMCI deliverables, and satisfaction of beneficiaries.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; MEDLINE; EMBASE, Ovid; the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EbscoHost; the Latin American Caribbean Health Sciences Literature (LILACS), Virtual Health Library (VHL); the WHO Library & Information Networks for Knowledge Database (WHOLIS); the Science Citation Index and Social Sciences Citation Index, Institute for Scientific Information (ISI) Web of Science; Population Information Online (POPLINE); the WHO International Clinical Trials Registry Platform (WHO ICTRP); and the Global Health, Ovid and Health Management, ProQuest database. We performed searches until 30 June 2015 and supplemented these by searching revised bibliographies and by contacting experts to identify ongoing and unpublished studies.
SELECTION CRITERIA
We sought to include randomised controlled trials (RCTs) and controlled before-after (CBA) studies with at least two intervention and two control sites evaluating the generic IMCI strategy or its adaptation in children younger than age five, and including at minimum efforts to improve health care worker skills for case management. We excluded studies in which IMCI was accompanied by other interventions including conditional cash transfers, food supplementation, and employment. The comparison group received usual health services without provision of IMCI.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened searches, selected trials, and extracted, analysed and tabulated data. We used inverse variance for cluster trials and an intracluster co-efficient of 0.01 when adjustment had not been made in the primary study. We used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) approach to assess the certainty of evidence.
MAIN RESULTS
Two cluster-randomised trials (India and Bangladesh) and two controlled before-after studies (Tanzania and India) met our inclusion criteria. Strategies included training of health care staff, management strengthening of health care systems (all four studies), and home visiting (two studies). The two studies from India included care packages targeting the neonatal period.One trial in Bangladesh estimated that child mortality may be 13% lower with IMCI, but the confidence interval (CI) included no effect (risk ratio (RR) 0.87, 95% CI 0.68 to 1.10; 5090 participants; low-certainty evidence). One CBA study in Tanzania gave almost identical estimates (RR 0.87, 95% CI 0.72 to 1.05; 1932 participants).One trial in India examined infant and neonatal mortality by implementing the integrated management of neonatal and childhood illness (IMNCI) strategy including post-natal home visits. Neonatal and infant mortality may be lower in the IMNCI group compared with the control group (infant mortality hazard ratio (HR) 0.85, 95% CI 0.77 to 0.94; neonatal mortality HR 0.91, 95% CI 0.80 to 1.03; one trial, 60,480 participants; low-certainty evidence).We estimated the effect of IMCI on any mortality measured by combining infant and child mortality in the one IMCI and the one IMNCI trial. Mortality may be reduced by IMCI (RR 0.85, 95% CI 0.78 to 0.93; two trials, 65,570 participants; low-certainty evidence).Two trials (India, Bangladesh) evaluated nutritional status and noted that there may be little or no effect on stunting (RR 0.94, 95% CI 0.84 to 1.06; 5242 participants, two trials; low-certainty evidence) and there is probably little or no effect on wasting (RR 1.04, 95% CI 0.87 to 1.25; two trials, 4288 participants; moderate-certainty evidence).The Tanzania CBA study showed similar results.Investigators measured quality of care by observing prescribing for common illnesses at health facilities (727 observations, two studies; very low-certainty evidence) and by observing prescribing by lay health care workers (1051 observations, three studies; very low-certainty evidence). We could not confirm a consistent effect on prescribing at health facilities or by lay health care workers, as certainty of the evidence was very low.For coverage of IMCI deliverables, we examined vaccine and vitamin A coverage, appropriate care seeking, and exclusive breast feeding. Two trials (India, Bangladesh) estimated vaccine coverage for measles and reported that there is probably little or no effect on measles vaccine coverage (RR 0.92, 95% CI 0.80 to 1.05; two trials, 4895 participants; moderate-certainty evidence), with similar effects seen in the Tanzania CBA study. Two studies measured the third dose of diphtheria, pertussis, and tetanus vaccine; and two measured vitamin A coverage, all providing little or no evidence of increased coverage with IMCI.Four studies (2 from India, and 1 each from Tanzania and Bangladesh) reported appropriate care seeking and derived information from careful questioning of mothers about recent illness. Some studies on effects of IMCI may report better care seeking behavior, but others do not report this.All four studies recorded maternal responses on exclusive breast feeding. They provided mixed results and very low-certainty evidence. Therefore, we do not know whether IMCI impacts exclusive breast feeding.No studies reported on the satisfaction of mothers and service users.
AUTHORS' CONCLUSIONS
The mix of interventions examined in research studies evaluating the IMCI strategy varies, and some studies include specific inputs to improve neonatal health. Most studies were conducted in South Asia. Implementing the integrated management of childhood illness strategy may reduce child mortality, and packages that include interventions for the neonatal period may reduce infant mortality. IMCI may have little or no effect on nutritional status and probably has little or no effect on vaccine coverage. Maternal care seeking behavior may be more appropriate with IMCI, but study results have been mixed, providing evidence of very low certainty about whether IMCI has effects on adherence to exclusive breast feeding.
Topics: Bangladesh; Breast Feeding; Child Health Services; Child Mortality; Child, Preschool; Controlled Before-After Studies; Delivery of Health Care, Integrated; Developing Countries; Disease Management; Health Personnel; House Calls; Humans; India; Infant; Infant Mortality; Program Evaluation; Quality Improvement; Randomized Controlled Trials as Topic; Tanzania
PubMed: 27378094
DOI: 10.1002/14651858.CD010123.pub2