BMC Public Health
(Accessed 22 November 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Determinants of vaccination coverage and adherence to the Greek national immunization program among infants aged 2-24 months at the beginning of the economic crisis (2009-2011)
Papaevangelou Vassiliki, Koutsoumbari Ioanna, Vintila Artemis, Klinaki Eleni, Zellos Aglaia, Achilleas Attilakos, Tsolia Maria and Kafetzis Dimitris
Author Affiliations
BMC Public Health 2014, 14:1192 doi:10.1186/1471-2458-14-1192
Published: 20 November 2014
Abstract (provisional)
Background
Childhood immunization has significantly reduced the incidence of vaccine preventable diseases. Parental mistrust over vaccine safety has been associated with vaccine refusal creating barriers on vaccine coverage. Recently, economic crisis has imposed additional impediment.
Methods
Study aim was to evaluate vaccine coverage among infants 2-24 months old in the Athens metropolitan area at the beginning of the economic crisis (2009-2011).
Results
Overall, 1,667 infants were enrolled (mean age 13 months). Less than 5% of parents admitted omitting or postponing vaccination secondary to their beliefs. Although vaccination coverage was acceptable for most vaccines, lower rates of immunization were found for some newer vaccines such as hepatitis A and rotavirus. Multiple regression analysis indicated that parental age, occupational, educational statuses and family size were independently associated with immunization coverage at 6 and 12 months. Interestingly, lack of insurance was not associated with missed vaccine doses.
Conclusion
Incomplete vaccination coverage was associated with socioeconomic factors. It becomes apparent, that reassessing vaccination priorities under the current economic situation may be needed.

Research article
Geographic information analysis and web-based geoportals to explore malnutrition in Sub-Saharan Africa: a systematic review of approaches
Sabrina Marx, Revati Phalkey, Clara Aranda, Jörn Profe, Rainer Sauerborn and Bernhard Höfle
Author Affiliations
BMC Public Health 2014, 14:1189 doi:10.1186/1471-2458-14-1189
Published: 20 November 2014
Abstract (provisional)
Background
Childhood malnutrition is a serious challenge in Sub-Saharan Africa (SSA) and a major underlying cause of death. It is the result of a dynamic and complex interaction between political, social, economic, environmental and other factors. As spatially oriented research has been established in health sciences in recent years, developments in Geographic Information Science (GIScience) provide beneficial tools to get an improved understanding of malnutrition.
Methods
In order to assess the current state of knowledge regarding the use of geoinformation analyses for exploring malnutrition in SSA, a systematic literature review of peer-reviewed literature is conducted using Scopus, ISI Web of Science and PubMed. As a supplement to the review, we carry on to investigate the establishment of web-based geoportals for providing freely accessible malnutrition geodata to a broad community. Based on these findings, we identify current limitations and discuss how new developments in GIScience might help to overcome impending barriers.
Results
563 articles are identified from the searches, from which a total of nine articles and eight geoportals meet inclusion criteria. The review suggests that the spatial dimension of malnutrition is analyzed most often at the regional and national level using geostatistical analysis methods. Therefore, heterogeneous geographic information at different spatial scales and from multiple sources is combined by applying geoinformation analysis methods such as spatial interpolation, aggregation and downscaling techniques. Geocoded malnutrition data from the Demographic and Health Survey Program are the most common information source to quantify the prevalence of malnutrition on a local scale and are frequently combined with regional data on climate, population, agriculture and/or infrastructure. Only aggregated geoinformation about malnutrition prevalence is freely accessible, mostly displayed via web map visualizations or downloadable map images. The lack of detailed geographic data at household and local level is a major limitation for an in-depth assessment of malnutrition and links to potential impact factors.
Conclusions
We propose that the combination of malnutrition-related studies with most recent GIScience developments such as crowd-sourced geodata collection, (web-based) interoperable spatial health data infrastructures as well as (dynamic) information fusion approaches are beneficial to deepen the understanding of this complex phenomenon.

Research article
Implementing effective hygiene promotion: lessons from the process evaluation of an intervention to promote handwashing with soap in rural India
Divya Rajaraman, Kiruba Sankar Varadharajan, Katie Greenland, Val Curtis, Raja Kumar, Wolf-Peter Schmidt, Robert Aunger and Adam Biran
Author Affiliations
BMC Public Health 2014, 14:1179 doi:10.1186/1471-2458-14-1179
Published: 19 November 2014
Abstract (provisional)
Background
An intervention trial of the ‘SuperAmma’ http://www.superamma.org/
village-level intervention to promote handwashing with soap (HWWS) in rural India demonstrated substantial increases in HWWS amongst the target population. We carried out a process evaluation to assess the implementation of the intervention and the evidence that it had changed the perceived benefits and social norms associated with HWWS. The evaluation also aimed to inform the design of a streamlined shorter intervention and estimate scale up costs.
Methods
Intervention implementation was observed in 7 villages. Semi-structured interviews were conducted with the implementation team, village leaders and representatives of the target population. A questionnaire survey was administered in 174 households in intervention villages and 171 households in control villages to assess exposure to intervention activities, recall of intervention components and evidence that the intervention had produced changes in perceptions that were consistent with the intervention core messages. Costs were estimated for the intervention as delivered, as well as for a hypothetical scale-up to 1,000 villages.
Results
We found that the intervention was largely acceptable to the target population, maintained high fidelity (after some starting problems), and resulted in a high level of exposure to most components. There was a high recall of most intervention activities and subjects in the intervention villages were more likely than those in control villages to cite reasons for HWWS that were in line with intervention messaging and to believe that HWWS was a social norm. There were no major differences between socio-economic and caste groups in exposure to intervention activities. Reducing the intervention from 4 to 2 contact days, in a scale up scenario, cut the estimated implementation cost from $2,293 to $1,097 per village.
Conclusions
The SuperAmma intervention is capable of achieving good reach across men and women of varied social and economic status, is affordable, and has the potential to be effective at scale provided that sufficient attention is given to ensuring the quality of intervention delivery.

Research article
Descriptive characterization of the 2010 cholera outbreak in Nigeria
Mahmood Muazu Dalhat1*, Aisha Nasiru Isa1, Patrick Nguku1, Sani-Gwarzo Nasir2, Katharina Urban1, Mohammed Abdulaziz1, Raymond Salanga Dankoli1, Peter Nsubuga3 and Gabriele Poggensee1
Author Affiliations
BMC Public Health 2014, 14:1167 doi:10.1186/1471-2458-14-1167
Published: 16 November 2014
Abstract
Background
In 2010, 18 States of Nigeria reported cholera outbreaks with a total of 41,787 cases including 1,716 deaths (case-fatality rate [CFR]: 4.1%). This exceeded the mean overall CFR of 2.4% reported in Africa from 2000–2005 and the WHO acceptable rate of 1%. We conducted a descriptive analysis of the 2010 cholera outbreak to determine its epidemiological and spatio-temporal characteristics.
Methods
We conducted retrospective analysis of line lists obtained from 10 of the 18 states that submitted line lists to the Federal Ministry of Health (FMOH). We described the outbreak by time, place and person and calculated the attack rates by state as well as the age- and sex-specific CFR from cholera cases for whom information on age, sex, place of residence, onset of symptoms and outcome were available.
Results
A total of 21,111 cases were reported with an overall attack rate and CFR of 47.8 cases /100,000 population and 5.1%, respectively. The CFR ranged in the states between 3.8% and 8.9%. The age-specific CFR was highest among individuals 65 years and above (14.6%). The epidemiological curve showed three peaks with increasing number of weekly reported cases. A geographical clustering of LGAs reporting cholera cases could be seen in all ten states. During the third peak which coincided with flooding in five states the majority of newly affected LGAs were situated next to LGAs with previously reported cholera cases, only few isolated outbreaks were seen.
Conclusion
Our study showed a cholera outbreak that grew in magnitude and spread to involve the whole northern part of the country. It also highlights challenges of suboptimal surveillance and response in developing countries as well as potential endemicity of cholera in the northern part of Nigeria. There is the need for a harmonized, coordinated approach to cholera outbreaks through effective surveillance and response with emphasis on training and motivating front line health workers towards timely detection, reporting and response. Findings from the report should be interpreted with caution due to the high number of cases with incomplete information, and lack of data from eight states.