Background: The vertical transmission of HIV from mother to child ranges from 15 to 40%. The preventing mothers to child transmission programme (PMTCT) services have been introduced during the past five years in South Africa; however vertical transmission of HIV remains high. Objectives: The objectives of the study were: 1. To describe the clinical and demographic characteristics of women attending the ANC clinic and delivering at the Germiston Hospital; 2. To determine the proportion of women who were offered voluntary counselling and testing (VCT) in 2004; 3. To determine the proportion of women who subsequently received PMTCT. Methods: This is a cross-sectional study I which a sample of 776 patient files were retrospectively, systematically and randomly sampled from 1, 500 antenatal files for the period 2004 (Jan-Dec), in an urban district hospital in the Gauteng Province. A checklist was used to extract specific information. Data was entered into EpiData and analysed using STATA version 8. Pearson's chi-square test was used to obtain measures of association for all categorical variables. The multiple logistic regression method was used to investigate predictors for missed PMTCT opportunities. Results: The pre_yalence proportion of syphilis was 14.19% {95%CI (11.81-16.85)}; prevalence proportion ofHIV was 33.76% {95% CI (27.53-37.13)}. The mean age ofthe sample population was 26.37 years (min=22, max=30). Forty eight per cent of the sample had registered late in the third trimester of pregnancy. Pregnant women presenting with syphilis were more likely to have a missed PMTCT opportunity {OR=2.2, 95%CI (1.16- 4.20), p=0.02}. Women having made fewer than two ANC visits were more likely to have a missed PMTCT/VCT opportunity than women having made more than two visits {OR=O.Sl, 95%CI (0.30-0.86), p=O.Ol}. Conclusions: The prevalence proportion of HIV is high in this setting (33%) and the prevalence of syphilis is seven times greater than the national prevalence. Every antenatal care visit is an opportunity for the healthcare worker to offer voluntary counselling and testing. All women identified as having syphilis infection are at high risk of acquiring HIV. Therefore every woman identified and treated for syphilis should be counselled and tested for HIV. Women must be offered HIV and AIDS education at every ANC visit. Routine opt-out counselling should be offered at every ANC visit for those who have not been previously tested. Recommendation: In order to increase the uptake of the PMTCT programme healthcare workers should have training and re-orientation on: 1. The need to use every opportunity in antenatal care and maternity wards to offer HIV counselling and testing to mothers; 2. HIV and AIDS in pregnancy, PMTCT, as well as the treatment and care of pregnant women. / Dissertation (MPH)--University of Pretoria, 2006. / School of Health Systems and Public Health (SHSPH) / MPH / Unrestricted

La vaccination est une des meilleures procédures de prévention coût-efficaces. Des couvertures vaccinales non adéquates présentent des problèmes de Santé publique considérables. Réduire ou éliminer les occasions manquées de vaccination (OMV) dans les régions les plus vulnérables permettrait d’y augmenter la couverture vaccinale. L’Inde a un des plus grands programmes de vaccination dans le monde, cependant il y existe d’importants gradients de couvertures vaccinales d’une région à l’autre. Objectifs : Cette étude visait à estimer la prévalence des OMV chez des jeunes enfants en zone rurale de Hardoi en Inde et identifier les potentiels déterminants et facteurs prédictifs des OMV. Méthodes : Les données secondaires d’une étude pré-post ont été utilisées pour mener une étude transversale. Les OMV ont été définies selon la définition de l’Organisation mondiale de la santé. Deux sources d’information sur le statut vaccinal ont été considérées : mémoire des mère ou carnet de vaccination (M/C) pour les analyses principales; et carnet de vaccination seulement (CS) en analyse de sensibilité. La prévalence des OMV dans la première année de vie (OMV-1AV) chez les enfants de 12 à moins de 24 mois et celle des OMV pendant la période optimale de vaccination (OMV-PO) chez les 0 à moins de 24 mois ont été calculées par sexe et bloc administratif. Les potentiels déterminants des OMV ont été identifiés à l’aide de modèles hiérarchiques. Des modèles prédictifs ont été construits pour identifier les facteurs qui permettraient de mieux cibler les enfants plus à risque d’OMV: leur pouvoir prédictif a été évalué avec la statistique c. Résultats : La prévalence des OMV-1AV selon la source M/C est de 19,3% ; celle selon CS est de 76,0%. La prévalence des OMV-PO selon M/C est de 14,6% alors qu’elle est de 65,7% selon CS. Pour les OMV-1AV et les OMV-PO, la prévalence variait d’un vaccin à l’autre mais seulement selon CS. Les déterminants des OMV varient selon la source d’information sur le statut vaccinal. Les principaux potentiels déterminants selon M/C sont: problèmes logistiques (OMV-1AV Rapport de cotes (RC) = 3,38; OMV-PO RC = 2,59); malaise ressenti chez l’enfant (OMV-1AV RC = 0,37; OMV-PO RC = 0,52); refus des vaccinateurs de vacciner sans avoir le carnet de vaccination (OMV-1AV RC = 5,66; OMV-1AV RC = 5,23); effets secondaires (OMV RC = 8,24; OMV-PO RC = 5,62); et le fait qu’un membre de la famille s’oppose à la vaccination de l’enfant; (OMV-1AV RC = 4,03; OMV-PO RC = 4,61). Des modèles prédictifs efficaces ont été construits et présentaient des statistiques c variant entre 0,72 et 0,79. Certains facteurs permettaient d’améliorer le pouvoir prédictif des modèles sans être nécessairement des potentiels déterminant des OMV tel que le temps de déplacement à pied entre le ménage et le centre de vaccination. Retombées : Les résultats suggèrent que la situation des OMV est complexe que ce soit du point de vue de la source d’information sur le statut vaccinal, de l’identification de leurs potentiels déterminants ou sur la capacité à cibler les individus les plus à risque. Les divergences au niveau des estimations de la prévalence selon la source d’information soulignent l’importance d’assurer un meilleur contrôle de la validité des sources d’information afin de maximiser l’exactitude des informations fournies. / Introduction: Missed opportunities for vaccination (MOV) affect vaccination coverages and contribute to create considerable vaccination gradient between and within regions. In India, despite major vaccination accomplishments, important vaccination gradients persist. MOV have been reported but the situation is not well known in many parts of the country. Aim: Quantify MOV in children in rural Hardoi district and identify potential determinants and predictive factors. Methods: We defined MOV using the definition of the World Health Organization. Our outcomes were missed opportunities for vaccination in first year of life (MOV-FYL) and missed opportunities for on-time vaccination (MO-OTV). We used a cross-sectional design. Vaccination status was verified according to two sources: by mothers’ recalls OR children vaccination card for the main analysis; and by vaccination card only for sensitivity analysis. We calculated the prevalence of both outcomes in a clustered population of 0 to under 24month-old children recruited in a census-like manner from rural area in Hardoi, India. We used multilevel binary logistic regression to identify potential determinants of MOV and multivariable logistic regression to built prediction models. Results: The prevalence was 19.30% and 14.39% for MOV-FYL and MO-OTV respectively. There were little variations across child sex and vaccines. However, among vaccination cardholders, the prevalence was 75.99% and 65.73% for MOV-FYL and MO-OTV respectively and varied across vaccines. Marked potential determinants using the main source of information about vaccination status were: logistics problems (MOV-FYL Odds Ratio (OR) = 3.38; MO-OTV OR = 2.59); child feeling unwell (MOV-FYL OR = 0.37; MO-OTV OR = 0.52); the refusal of health provider to vaccinate without the vaccination card (MOV-FYL OR = 5.66; MO-OTV OR = 5.23); side effects (MOV-FYL OR = 8.24; MO-OTV OR = 5.62); and family member not allowing vaccination (MOV-FYL OR = 4.03; MO-OTV OR = 4.61). Predictive models for MOV-FYL and MO-OTV yielded c statistics around 0.72 and 0.79 respectively and had the best sensitivity/specificity balance when used in a population with 15%-20% probability of MOV. Conclusion: Our study revealed that quantifying the prevalence of MOV is rather complexed. The source of information about vaccination status is key to obtain the best estimates, hence the knowledge on the reliability of the information from the card or obtained from recalls is a must. Many potential modifiable determinants should be explored and there is potential for predictability: interventions should be developed to reduce risks of MOV in targeted individuals, increase vaccination coverage and reduce vaccination gradients.