Mac, Lisa Marie (2014)

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Purpose: Rotavirus is a common cause of severe and fatal diarrhea in children under five, with 95% of deaths occurring in developing countries. Bolivia, a developing country in South America, introduced the rotavirus vaccine, Rotarix, in 2008. It has been demonstrated that adherence to vaccination timelines in middle and low income countries is low, thus hindering true disease protection. There is a need to assess adherence to the rotavirus immunization timeline, as 15% of deaths in Bolivian children under five are caused by diarrheal disease.

Goal: To evaluate the timing of the Rotarix vaccine series, and possible barriers/incentives to receiving the vaccine within the recommended timeframe, among infants in El Alto, Bolivia.

Methods: Caregivers with infants ≥ 8 months or a completed Rotarix series were recruited from the Los Andes and Corea hospitals. They completed a questionnaire inquiring about demographics, rotavirus vaccine knowledge, and beliefs regarding rotavirus vaccine safety and importance. Infant birthdate and immunization dates were collected from each infant's vaccination card. A multivariable logistic regression model was used to analyze the effect of variables on timely completion of two vaccine schedules.

Results: Approximately 61% of infants received their first dose within 8-9 weeks since birth and 66% received their second dose within 17-18 weeks since birth. Over 97% of infants were vaccinated according to the Bolivian MOH rotavirus immunization timeline, while only 51% adhered to the 2, 4-month clinician recommended timeline. Barriers could not be assessed for the MOH timeline because of its timely receipt, however knowing other vaccinated infants and believing the rotavirus vaccine was safe were statistically significant (p<0.05) for the clinician recommended timeline.

Conclusion: Caregivers exhibited a high level of adherence to the MOH immunization timeline, possibly due to simultaneous vaccination and immunization-only services within comprehensive care hospitals. Adherence to the clinician recommended timeline was poor, however, possibly due to personal, non-structural issues between caregivers and providers. Better communication and education regarding the specified 2, 4 month schedule is needed. If caregivers continue having difficulty complying with the clinician recommended schedule, infants will continue to be at risk, despite adherence to the MOH timeline.

Table of Contents

List of Tables and Figures 1

Literature Review 3

I. Diarrheal Disease 3

Global Burden of Diarrheal Disease 3

Implications of Rotavirus Infection 4

II. Diarrheal Disease Vaccine Intervention 5

Rotavirus Vaccine 5

Global Rotavirus Vaccine Efficacy 5

Global Rotavirus Vaccine Effectiveness 6

III. Adherence to Vaccine Schedules 7

Adherence to Rotarix Vaccine Schedule 7

Adherence to Pediatric Vaccine Schedules Globally 8

IV. Known Barriers and Incentives to Adherence 10

National Pediatric Timelines 10

Clinician Recommended Timelines 10

V. Bolivia 12

Burden of Diarrheal Disease in Bolivia 12

Burden of Rotavirus Infection in Bolivia 12

Economic Impact of Diarrheal Disease and Rotavirus Infection in Bolivia 13

Rotavirus Vaccination in Bolivia 14

Rotavirus Vaccine Coverage Rates in Bolivia 14

Rotavirus Vaccine Efficacy in Bolivia 15

Rotavirus Vaccine Effectiveness in Bolivia 16

Adherence to Rotarix Schedule in Bolivia 16

VI. Research Goals 17

VII. Significance of the Study 18

Introduction 20

Materials and Methods 25

I. Study Area 25

II. Sample Size Calculation 25

III. Study Population 26

IV. Recruitment 26

V. Enrollment and Consent 27

VI. Study Instrument 27

VII. Data Collection 29

VIII. Data Management 29

IX. Statistical Analysis 30

Timeliness with Bolivian Ministry of Health Rotavirus Immunization Schedule 30

Timeliness with Clinician Recommended 2, 4-month Immunization Schedule 31

Description of Models Used 31

Independent Variables Contained in the Adaptation of the Systems Model of Clinical Preventive Care 32

Model 1: Predisposing Factors Associated with Failure of Adhering to the Clinician Recommendation of Rotarix 2, 4 Month Dosage Schedule 33

Model 2: Predisposing, Enabling, Reinforcing, Preventive Activity, and Situational Factors Associated with Failure of Adhering to the Clinician Recommendation of Rotarix 2, 4 Month Dosage Schedule 33

Results 35

Discussion 38

Public Health Implications 46

References 47

Appendix 1 58

Appendix 2 59

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