What’s Being Done to Promote Vaccinations Across the Globe?

August is National Immunization Awareness Month (NIAM)! Every year, the public health community focuses on spreading awareness of the importance of vaccinations for people of all ages. There are four main messages that are promoted through this campaign:

1) Vaccines protect against serious diseases

2) These diseases still exist and outbreaks do occur

3) Vaccines are recommended throughout our lives

4) Vaccines are very safe.

The United States backs up the importance of these messages with strict school attendance policies regarding vaccinations. Each state has their own laws, but they each require vaccines for children not only attending public schools, but also private schools, universities and daycares. All states allow for medical exemptions, but only some states offer religious or philosophical exemptions. In addition to these policies, the country pushes out amazing social media campaigns that focus on this observance in August. These messages are promoted in many diverse social media outlets in the United States. To name a few, the National Public Health Information Coalition has a toolkit with multiple social media strategies promoting on-time vaccination, and the American Academy of Pediatricians has created and shared a video with many doctors across the country sharing their perspective on why they vaccinate. There are dozens of news articles published everyday with questions and answers regarding the importance of vaccines and reminding parents to get their kids vaccinated before school starts. There are even great articles stressing the importance of adult vaccination – which we don’t see very often! So much good material is pushed out towards the public during this month to promote the truth in how they protect ourselves and our communities.

From an international health perspective, diseases impact everyone, all over the globe.

What are some things being done in other countries around the world? Do they encourage and push out vaccine efforts and policies as much as the United States? Is it just as important?

It turns out, yes! Vaccines are important in many different countries across the world. Here’s a quick spotlight from CNN and other current articles on a few countries that have recently improved their efforts through policy to increase vaccination rates in their countries.

France just passed a new law that requires all children born after January 1st to receive 11 mandatory vaccines. The Ministry of Health is trying to increase their vaccination coverage to meet the World Health Organization’s recommendation of 95% with this new law. The ministry did not want to use forceful methods to motivate the public into getting vaccinated, however this new law will strongly incentivize parents to get their children their shots – otherwise they will not be allowed to attend schools or daycares.

To address the recent measles outbreaks going on in Europe, Italy has followed the United States’ lead and required vaccinations for school entrance. However, they are different from the United States because they are NOT allowing conscientious objections and their citizens will be issued a fine if they do not choose to vaccinate.

Germany recently introduced legislation that makes it required for Kindergarten schools to report to their health departments any parents who have not submitted proof of vaccination for their children. The vaccinations have been required in the past, however reporting parents to the health department is a new stronger twist in ensuring vaccination coverage in schools across the country.

Canada has worked on increasing their vaccination rates by combining vaccine appointments with their routine check ups, providing home visits, creating more vaccine clinics and sending out reminders. This makes it easier for those living further out from clinics and larger cities to get their kids’ vaccination needs taken care of.

In 2016, Australia’s government passed a law that allows families with lower incomes to get “tax rebates” if they keep their child up to date on vaccines. More than 210,000 families have participated since the program was implemented in January 2016 – that’s a lot of kids vaccinated!

On August 6th, 2018, Brazil launched a nationwide vaccination campaign for measles and polio after a large outbreak of measles that resulted in five children deaths. In states where measles is more concentrated, the Ministry of Health has given out free shots in clinics and citizen homes. Their ambitious goal is to vaccinate 95% of children ages 1 to 5 by the end of August.

In an article by Nicholas Dugan, we see that progress has been made in the South Asian countries of Nepal and Bhutan regarding 90% diptheria-tetanus-pertussis (DTP3) coverage since the adoption of the Global Vaccine Action Plan (GVAP) in 2012. Bangladesh has also increased their DTP3 rates by over 20% after the 1980’s when they invested in health infrastructure and training regarding immunizations. These rates are encouraging to hear, as the region of South Asia has typically lagged behind other regions in their vaccination requirement efforts.

Lastly, about 20 million infants worldwide have not been reached through immunizations services and about 60% of those 20 million can be pinpointed to live in 10 countries: Afghanistan, Angola, the Democratic Republic of Congo, Ethiopia, India, Indonesia, Iraq, Nigeria, Pakistan and South Africa. The WHO is working with these countries through initiatives like the Global Vaccine Action Plan mentioned above. In 2017, the GVAP was revamped to further encourage government to improve monitoring and surveillance systems regarding immunization rates so that the data from these systems is up to date and able to guide policy and decision-making for the future. It also requests the WHO Secretariat support these countries continuously to achieve these goals.

Overall, each of these country policies are a little different, but they all encourage and strive to increase vaccination coverage in their respective countries – some with help from other organizations like the WHO.  Over the last few years, the proportion of children across the world with recommended vaccines has stayed stable according to the World Health Organization. With all of these different methods for bringing awareness to the importance of vaccinations through social media this month and different health policies around the world, I am encouraged and optimistic about efforts to increase the proportion of children across the world covered by these essential vaccinations.

Getting involved with health policies that encourage vaccinations is worthwhile and leads to great changes in many different countries as seen above, but if you want to be involved in a smaller (but still impactful) way, I’ve included a few different resources you can use via social media, regardless of where you live, and do your part in increasing awareness and importance of vaccines during the month of August:

  • Health.gov’s toolkit (includes information to add to a newsletter, tweets, community events)
  • American Academy of Pediatricians toolkit (blogs and articles to share)
  • CDC’s recommended immunization schedule

Retweet, post and share away the importance of this observance!

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Happy Breastfeeding Week! #WBW2018

World breastfeeding week takes place from August 1st to 7th this year. This year’s theme is Breastfeeding: Foundation of Life.

There are tools for all of your advocacy and information needs!

WHO has infographics and webinar information: http://www.who.int/news-room/events/detail/2018/08/01/default-calendar/world-breastfeeding-week-2018

The World Alliance for Breastfeeding Action (WABA) has an action folder in several languages (http://worldbreastfeedingweek.org/actionfolder/) and a social media toolkit (http://worldbreastfeedingweek.org/social-media-kit/).

WABA is also hosting a Thunderclap! Those who join will automatically share the same breastfeeding message at the same time across FaceBook and Twitter on August 1. https://www.thunderclap.it/projects/70825-world-breastfeeding-week-2018

In related news: In the U.S., Idaho and Utah recently passed bills legalizing breastfeeding in public for their residents. It is now legal in all 50 U.S. states to breastfeed in public. Appropriately, this week also kicks off our own National Breastfeeding Month in the U.S. (http://www.usbreastfeeding.org/nbm).

Weekly themes:

  • Week 1: Policy Pulse 
    Finding Solutions: Small policy changes can go a long way toward supporting breastfeeding families
  • Week 2: Special Circumstances & Emergency Preparedness 
    Always Ready: Resources and guidance on how to manage feeding during an emergency
  • Week 3: Call to Action 
    Answering the Call: Everyone can help make breastfeeding easier
  • Week 4: Black Breastfeeding Week 
    Love on Top: On top of joy, on top of grief, on top of everything

Happy messaging! Support breastfeeding everyday!

 

Outcomes of Global Intimate Partner Violence

This is the third part of a IH Blog series featured this summer, Intimate Partner Violence: Global Burden, Risk Factors and Outcomes.

Written by: Erica Hartmann MPH, MMS (c) and Dr. Heather de Vries McClintock PhD MSPH MSW

Intimate partner violence (IPV) is defined by the Center for Disease Control (CDC) as physical violence, sexual violence, stalking and psychological (or emotional) aggression by a current or former intimate partner (Violence Prevention, 2017). Consequences of intimate partner violence (IPV) can be immediate, long lasting, and invisible. The physical impact of  IPV includes broken bones, lost teeth, hearing damage, and vocal cord damage due to attempted strangulation (Garcia-Moreno C et al., 2005). The World Health Organization’s multi-country study showed that women who were ever abused by their partner were twice as likely to report poor health and physical and mental problems when compared to women who were never abused (Garcia-Moreno C et al., 2005). Diagnoses resulting from IPV include irritable bowel syndrome, fibromyalgia, chronic pain syndromes, and asthma exacerbation (Crofford, 2007; Heise,Garcia Moreno, 2002). Additionally, violence during pregnancy is associated with miscarriage, late entry into prenatal care, stillbirth, premature labor, fetal injury, and low birthweight (Bailey, 2010; Garcia-Moreno C et al., 2005; Silverman, Decker, Reed, and Raj, 2006). IPV can have lasting, and often unseen consequences.

Intimate partner violence can be harmful to the victim and to the children in the home where violence is occuring. Studies from around the globe find that IPV is a leading predictor of child maltreatment (Hunter, et al., 2000; Family Violence Prevention Fund, 2006). Growing up in a home where the mother experienced violence is considered an adverse childhood experience, and is associated with greater likelihood of poor outcomes in later life such as alcoholism, drug abuse, and suicide attempts (Felitti, 1998).

Intimate partner violence (IPV) has previously been linked with child mortality in countries including Bangladesh, the United States, India, Malawi, and Timor Leste (Hossain, Sumi, Haque, Bari, 2014; Mwale, 2004; Silverman et al., 2011; Taft, Powell, and Watson, 2015; Garoma, Fantahun,and Worku, 2012). A recent study using data from the Timor Leste’s 2013 Demographic Health Survey (DHS) showed that women who experienced physical violence were 30% more likely to experience child loss (the death of one or more children), and women who experienced combined forms of violence were 45% more likely to experience child loss when compared with women who had not experienced violence (Taft, Powell, and Watson, 2015).

We sought to uncover the relationship between intimate partner violence and child loss using the Togo demographic health survey (DHS) administered between 2013-2014. In addition, we investigated the effect of emotional violence which to our knowledge, has not been investigated in associated with child loss.  The Demographic Health survey is a nationally representative household survey that is administered by the United States Agency for International Development (USAID). This survey provides a wide range of monitoring and impact evaluation indicators and is developed in collaboration with the surveyed country. The Togo 2013-2014 DHS survey was translated into 13 languages and was administered by 90 highly trained individuals after gaining privacy and consent of the participant. The DHS survey assessed lifetime victimization of physical, emotional, and sexual violence (yes/no), and child loss (difference between the number of childbirths and number of living children, 1 or more coded as yes/ 0 coded as no). Covariates assessed included age, education, marital status, wealth index, employment, justification of wife-beating, and urban/rural residence. Data were weighted and analyzed through a bivariate logistic regression adjusting for covariates using SPSS version 14.

In total, 4842 Togolese women completed the domestic violence module of the Demographic health survey. In all, 36.5% of women reported victimization of physical, sexual, or emotional IPV in their lifetime. Women who experienced any form of IPV were 1.415 times as likely to experience child loss when compared to women who never experienced IPV (adjusted odds ratio (AOR) =1.415, 95% confidence interval (CI)=1.227,1.633). Women were significantly more likely to experience child loss if they experienced physical IPV (AOR=1.340, 95% CI = 1.135,1.582), sexual IPV (AOR=1.488, 95% CI = 162,1.905) or emotional IPV (AOR= 1.325, 95% CI = 1.143,1.536). Women who experienced combined forms of violence were at significantly increased odds of experiencing a child’s death when compared to women who never experienced violence (AOR=1.479, (95%CI = 1.231,1.778). We saw a significant association between all forms of intimate partner violence and child loss among this population of Togolese women. This finding indicates a need for child mortality interventions that address intimate partner violence to reduce Togo’s child mortality rate.

Addressing IPV requires strategies implemented at the individual, community, and policy levels. Screening for intimate partner violence during prenatal visits and providing social worker counseling to future mothers reduces recurrent episodes of IPV and improves childbirth outcomes (leading to higher birth weights and fewer premature births) (Kiely, Elmohandes, El-khorazaty, & Gantz, 2011). Data also indicates that policies including support programs for survivors such as shelters, housing programs, legal services, have been effective in reducing negative outcomes. The World Health Organization outlines strategies through which policy can most effectively reduce the burden of IPV suggesting that the healthcare and other sectors should have minimum standards for addressing this issue. These standards include establishing clear working protocols encompassing clear referral pathways for survivors of IPV (WHO Response to IPV, 2016). The degree to and nature in which countries follow these recommendations varies dramatically with some countries aggressively attempting to address the issue while others failing to even acknowledge its existence. The consequences of IPV are vast and impact people all over the world. Public health professionals are at the forefront of tackling this issue and will continue to play a critical role in reducing the global burden of IPV.

Please stay tuned for Part IV in this series: Interventions and Strategies for Addressing Global Intimate Partner Violence.

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Erica Hartmann, MMS (c), MMS (c) 2020 is a student at Arcadia University who hopes to prevent violence by serving as a physician assistant specializing in primary care in communities with limited access to healthcare. Erica worked under Dr. Heather McClintock to uncover links between IPV and child loss in Togo, and hopes to continue researching global violence prevention interventions after graduating from Arcadia.

McClintock.PictureDr. Heather F. de Vries McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life and Integrating Management for Depression and Type 2 Diabetes Mellitus Studies.

References:

Bailey, B. A. (2010). Partner violence during pregnancy: prevalence, effects, screening, and management. International Journal of Women’s Health, 2, 183–197.

Crofford LJ. (2007) Violence, stress, and somatic syndromes. Trauma Violence Abuse; 8:299–313.

Garcia-Moreno C et al. (2005). WHO multi-country study on women’s health and domestic
Violence.

Garoma, S., Fantahun, M., & Worku, A. (2012). Maternal Intimate Partner Violence Victimization and under-Five Children Mortality in Western Ethiopia: A Case-Control Study. Journal of Tropical Pediatrics, 58(6), 467-474. doi:10.1093/tropej/fms018

Heise L, Garcia Moreno C. (2002). Violence by intimate partners. In: Krug EG et al., eds.

Hunter WM et al. (2000). Risk Factors for Severe Child Discipline Practices in Rural India. Journal of Paediatric Psychology, 25: 435–447.

Hossain, Sumi, Haque, Bari. (2014). Consequences of Intimate Partner Violence Against Women on Under- Five Child Mortality in Bangladesh. Journal of Interpersonal Violence, 29(8) 1402-1417.

Family Violence Prevention Fund (2006). Programs: Children and Domestic Violence. Family Violence Prevention Fund. Available at: http://endabuse.org/ programs/children/.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . .
Marks, J. S. (1998). Relationship of Childhood Abuse and Household Dysfunction to
Many of the Leading Causes of Death in Adults. American Journal of Preventive
Medicine, 14(4), 245-258. doi:10.1016/s0749-3797(98)00017-8

Kiely, M., El-mohandes, A. A. E., El-khorazaty, M. N., & Gantz, M. G. (2011). An Integrated Intervention to Reduce Intamate Partner Violence in Pregnancy: A Randomized Controlled Trial, 115, 273–283. https://doi.org/10.1097/AOG.0b013e3181cbd482.AN

Mwale (2004). Infant and Child Mortality in Malawi. Neonatal and Child Mortality. pp 123-132.

Runyan D et al. (2002). Child Abuse and Neglect by Parents and Other Caregivers. In: Krug EG et al. (Eds). World Report on Violence and Health. Geneva, World Health Organization, pp 59–86.

Silverman, J. G., Decker, M. R., Reed, E., & Raj, A. (2006). Intimate partner violence
victimization prior to and during pregnancy among women residing in 26 U.S. states:
Associations with maternal and neonatal health. American Journal of Obstetrics and
Gynecology, 195(1), 140-148. doi:10.1016/j.ajog.2005.12.052 

Taft, A. J., Powell, R. L., & Watson, L. F. (2015). in Timor-Leste, (July 2014), 177–181.
https://doi.org/10.1111/1753-6405.12339

Violence Prevention. (2017). Retrieved October 03, 2017, from
https://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html

 

Attacks on Healthcare are Beyond the Limits of War

In the spring of 2016, the 15 members of the United Nations Security Council adopted Resolution 2286, which had been cosponsored by more than 80 Member States. The issue behind the Resolution, which brought such overwhelming support from a sometimes fractious body, was the increase in attacks on medical staff and facilities in conflict zones. The Resolution was broad, covering attacks or threats against patients, personnel, transportation mechanisms, and medical facilities. It emphasized that such attacks are not only detrimental to those immediately affected, but for the long-term consequences on already fragile health outcomes and systems. Of course, these protections are not new, codified by the Geneva Conventions in 1949 and the Additional Protocols from 1977 and 2005. However, an unprecedented number of attacks on health, many of which were occurring in the same few countries, led to this new push to pressure antagonists to cease their attacks and provide medical and humanitarian personnel with their due protections under humanitarian and human rights law. “Even wars have rules,” said then-UN Secretary-General Ban Ki-moon.

Despite the strong words from the UN and organizations like Médecins Sans Frontières (MSF) and the International Committee of the Red Cross (ICRC), little action was prompted by the newfound interest in health-related attacks. As a result, attacks have only increased since the year before the resolution was passed; while there were 256 attacks in 2015, there were 302 recorded attacks in 2016, 322 in 2017, and 149 attacks in the first quarter of 2018 alone. Not surprisingly, attacks in Syria propel the bulk of these numbers, with the Central African Republic, Pakistan, Libya, and Nigeria rounding out the top five countries featuring attacks in 2017. Of course, with the imperfect methods of collecting data in these fragile countries, as well as fears of witnesses or survivors to speak out about perpetrators, it is likely that more threats and attacks exist than can be captured by these data. In fact, as attacks continue and even proliferate, medical workers who risk their lives documenting attacks and their outcomes have questioned whether their work is worthwhile.

In these fragile countries, where access to health care is vital in maintaining a civilian population’s ability to stay, fifty-six health programs were closed due to increased insecurity to the facilities and staff in 2017. Ambulances are destroyed or hijacked. Health workers are arrested or kidnapped. Some countries have attacks that are more specific to the nature of their conflict- for example, the occupied Palestinian Territories, where movement restrictions are common, reported the highest numbers for obstruction to the provision of healthcare. In countries affected by polio, such as Nigeria, vaccination efforts are common targets of attacks. Countries where terrorist groups such as the Islamic State reside see reports of fighters disguised as medical personnel to attack or occupy hospitals. While the mechanism of attack differs, the outcomes are the same: terrorized civilians, diminished health infrastructure, demoralized health workers, prolonged conflict, and a frustrated but ultimately immobilized international community.

Despite these grim reports, there are still actions that can be taken by stakeholders of all levels that can hope to at least minimize these attacks. A two-pronged approach is required: one focusing on investigation and the other on penalties. First, a robust investigation and data collection mechanism must be developed and, most importantly, implemented where needed. MSF president Joanne Liu urged the UN Security Council to conduct robust, independent, and impartial investigations of such attacks, noting that previous calls for such initiatives have been disregarded. In almost all cases where investigations are conducted, they are led and settled by the perpetrator themselves. Independent, well-funded, and rigorous investigations, coupled with new methods of surveying and interviewing witnesses and survivors, should be supported by the UN and civil society in such nations. Additionally, it is apparent that such attacks persist due to the lack of consequences on offenders. Perpetrators on or allied with members of the UN Security Council would be tasked with condemning or punishing themselves and each other, unlikely in the current environment of norms in the international order. While a strengthening of the commitment of states to international humanitarian law is long overdue, in the meantime, action is not necessarily limited to the walls of the UN. Some humanitarian organizations, such as Oxfam, are taking a more direct approach, petitioning states to stop selling arms to countries that have used these weapons to attack civilian infrastructure like hospitals.

Addressing the World Humanitarian Summit in 2015, ICRC President Peter Maurer said “Wars without limits are wars without end. Limiting wars is an intrinsic test of our civilization, and probably of all civilized worlds.” Public health advocates must insist that the international community draws a line on protecting those serving the world’s most vulnerable in the most challenging environments imaginable. While war may be inevitable, the erasure of the human rights of those involved is entirely preventable through collective advocacy and action. Much of the needed action lies at the institutional level, but individuals concerned with these issues can follow social media campaigns like #NotATarget, started by the UN and the theme of World Humanitarian Day 2017, or support NGOs tasked with delivering healthcare in conflict environments, either on the local level or with international organizations such as the ICRC and MSF. Lastly, organizations like Safeguarding Health in Conflict, Insecurity Insight, and Physicians for Human Rights produce data and reports about these issues that can be used to direct advocacy or propel research efforts.

Support the best nutrition for babies everywhere: Urge your U.S. Representatives to protect, promote, and support breastfeeding!

Are you aware that representatives from the U.S. sided with commercial infant formula industry interests at the expense of babies during the recent World Health Assembly (WHA) meeting in Geneva?

Screen Shot 2018-07-17 at 4.48.44 PMU.S. officials at the meeting proposed the adoption of language that would have allowed this industry unrestricted ability to aggressively market breast milk substitutes as part of a WHA resolution on infant and young child feeding that included breastfeeding. Finally, the original wording of the resolution was mostly maintained. However, Ecuador had already been forced to withdraw its sponsorship of the resolution due to U.S. threats to withdraw military and commercial support if they didn’t, instilling fear in all other smaller countries of similar retaliation from the U.S. that may persist into the future. Russia stepped up at the end to sponsor the resolution because they said they support breastfeeding!

Support the best nutrition for babies everywhere.

Urge your U.S. Representatives to protect, promote, and support breastfeeding!

Act now by calling or writing your U.S. Representatives. Need the contact information for your representatives?

The issue and the circumstances are well articulated by two articles found in News Deeply and The New York Times.

For more information about IH Section’s Policy and Advocacy Committee activities, contact:
Kevin Sykes, PhD, MPH and Elizabeth Holguin, MPH, MSN, FNP-BC
APHA, International Health Section Policy and Advocacy Committee Co-Chairs