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Expanded Program on Immunizationin the mer icas

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Volume VI Number 6 IMMUNIZE AND PROTECT YOUR CHILD December 1984English speaking Caribbean and Suriname

Attaining higher coverage: Obstacles to overcome~ i g O l r i l a l l l p r o g r t s ~ has be,;n made 10 the ImproH mem

of imm uOIz;ltion coveraKt' in th e CQUnlneS of th e English~ p t a i n g Canbhean area including- UrJname O\( T thepast fi\f' years. Tht'countnes and lerrltones referred 10 inIhlo;; '{Touping- arC . Anguilla. Antigua and Barhuda.Bahamas. Barbados. Belize. Bermuda. Brllish \ ITgInIslands. Cayman Islands. Dommica. Grenada. Gu\'ana.Jamaica. l\loniserrat, St. C h r l ~ t O p h ( r N ( \ i } . SainI Luci


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available, coverage can then be monitored a t month lyintervals to determine if progress isadequate to achieve theannual target set for immunization coverage.

For example, a target of 90 immunization coverage isset for children under I year of age by the end of thecalendar year. Therefore, it will be necessary to completelyimmunize at l ea st 108 children 90 of 120) annually.Dividing this figure by 12, nine children per month willhave to be fully immunized to reach the t ar ge t set by t hehealth center.

The monitoring chart used by the Expanded Programon Immunization (EPI) in the Caribbean a re a is i de al forthis purpose. See P Newsletter //-6, December, /980 . Itshould be remembered that t he t ar ge t population is anestimate from the previous year s figures and may not beaccurate. At the end of each year, the final figures shouldbe reviewed and adjusted if necessary.

dministering P vaccinessimultaneouslyIn some cases health workers are reiuctant to administer

EPI vaccines simultaneously. This may be t he same childwho never returns to receive other immunizations nor tocomplete the DPT o r TOPV course.

Th e EPI Global Advisory Group recommends that oneach visit a child should be given as many EPI vaccines asare indicated by the age of the child. For example, a 3month old could be given DPT (intramuscular injection,See Editorial Note), BCG ( intradermal injection in theupper right arm) and TOPV drops in the mouth. Theadvantage of simultaneous administration of the vaccinesis reduction in the number of visits needed to complete theimmunization schedule.

Numerous scientific studies support simultaneous EPIvaccine administration. They also show that when giventogether vaccines are as effective o r ne ar ly so) as whengiven separately. Furthermore, sim ultaneous administration of the EPI \ accines does not increase the risk, reactions, or complications.

Immunizing ormalnourished children _Some children are seen at the health center only when

they are ill and may require treatment. Consequently, thehealth worker is faced with the problem of whether or notto immunize them. Each country should formulate itsown policies, preferably based on the advice of a broadlyconstituted advisory group. The policy should reflect apractical appraisal of the risks of the disease as well asbenefits and risks of immunization. Essential considerations include the availability and accessibility of healthcare services, patterns of utilization of these services, theability to identify and follow-up children who are notimmunized, the l ikel ihood that chi ldren will return forsubsequent immunization, and the sociocultural acceptability of specific procedures and r e c o m m e n d t i o n ~Recording and reporting

It is important to keep immunization records on thestandard reporting form at each level of the program. It isthe responsibility of the supervisor at each level to verifyt he f ig ur es and ensure all necessary act ions are takenpromptly. This includes forwarding reports to the centralauthority through a well-defined and efficient procedure.

A numberof immunizations performed by privatepr ctitioners and institutions are not reported. Both publicand private heal th care providers should agree upon astandardized reporting format and flow of informationthat will allow for a better estimation of coverage attained.Source: Henry Smith , CAREC, Adapted from Taking Care,1 5):13-15,1984.Editorial note: The last meeting of th e EPI Global AdvisoryGroup, which met in Alexandria, Egypt in October 1984, madeth e following recommendation on this subject. Countries areurged review current pranices regarding th e anatomical site ofintramuscular immunization. Taking into account the cri teriaof safety and ease of administration, thigh injection for DPTandarm injection for TT are strongly recommended.

anishing m sl s from th worldCan we eradicate measles? Should we eradicate measles?Will we eradicate measles?The answer to the first question rests on scientific facl.We can eradicate measles. The smallpox eradication pro

gram prm ed that the worldwide eradication of certaininfenious diseases is possi ble. Although there areobviousdifferences between measles and smallpox, there are alsoepidemiological similarities. They are both viruses thatcause recognizable rashes, a characteristic that is helpfulfor epidemiological surveillance programs. They bothconfer lifelong immunity. Neither has an animal reservoir2

or is harbored in inapparent chronic earners amonghuman beings.Since J 963, an effenive and safe vaccine for measles hasbeen a\ ailable, and it has been widely used in the SA andother countries. In the past it has not been pu t to maximum use becaus e a smoothly functioning cold chain ofstorage, transportation, and delivery was required to preserve the viability of the vaccine virus. There is now a ortheat-stable vaccine that can r emain pot en t i n the freezedried state for 3-4 weeks at ambient tropical temperatureswithout refrigeration. The containers thaI maintain low


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TIl{' dnll l l a rllt ld IS all l ' l 'uyday orrurrnlct ' marJV p a ( t ~ fhl' world; hOlI''''If'r. th;o morlallt}, rafl' c l ll ld rO l wuu ld hIIOUJrrf d II a ll cl ldrr l1 har n t u fo til,. r )1JfHlr TI la lTlallmH thatar;o alrrad)' (ommo1l/J/tur HI fhl' dnl;olo/)( d u.'m/d (Photo' PAlm solid. The ~ e c o n d question to be askt'd IS

Should we l'Tadica(' measles? In an era of ~ ( a r ( e global resources , ~ h o l i i d 1110n ) and lalenl be \pent onrradiC'al ion?Again, Ihe w('r is y('s-'\\,e should ('radicat(' measlesfor reasons relaled to bOlh health and economiC's. Measl('sa major source of u n n e ( e ~ s a r ) suffering, premalurt'

monalilY, and C xp nsC . Except in isolated populalions,measles is neilrl) universal, mOSt p e n o n ~ being infectedbdoH'r( lChmg Iheag-eof 15. Measles, under an) c il (umSl antes, C an (aUSt' ')t'riou'\ (om pi i a Iions. Amung Ihest' an 'diarrhea, encephalilis, O I i t i ~ media, pneumonia, andcxac('rb;:llion of protein energy malnulrilion. Therapy fOl

m e ~ l e ~ and (ompliralions is a major drain on medicalcare r e s O l l r c e ~ in mOSI of Africa, Asia . andAmerica (I).It h;:ls bCl'n (,lttimatt'd Ihal approximately 900000 dl'athltfrom measl('s OCUli each year in the developing world ( I).

In the Inler-American Invesligalion of MonalilY inChildhood i, was found ,hal measles is ,h e leading causeof death or lhe second leading cause in children aged 1-4years in several c il ies in Latin America (2). Measles oulbreaks in Africa and Asia have case-falalily rale') of 5 20among children, especially malnourished ones.Measles compliC'alions may also resul t in de\elopmen,al re'ardalion, lifelong handicap, and bolh direc, andIIldirecr ('conomic loss. Funhcrmorc, in children in thede\'e1oping world. measles inleracls with diarrheal diseaseand malnuLTition to increalie lhe morbidity and monalityfrom these conditions. In the develoJX'd nations, wherr lhedisea e is less severe and therearc faci lilies for saving lives.it is still importanl 10 eliminate measles.\Vhen the IIldigenous t ransmiss ion of measles(eased, the lTSA must COlli inur to bear Ihe C OSIS of roulinevaccination, suneillancc, and response 10 imponed casC suntil global eradication is achicv('d. has be('n estimaledIhal Ihese COSIS, for both IrealOlelll and prevention, may,x,eed S50 million a year. The earlier ,he /;Iobal,arge, oferadication is achieved, the sooner Ihe liSA can disconlinue Ihese expenditures. The nation bore lh > C'onsiderable lOSI of keeping i ts populi.Hion free of smallpox formore Ihan 25 years befort' Iheglobal small pox eradicalionprogram began. The $32 million inveo led in Ihe smallpoxeradicalion program over 12 years is now saved every 3monlhs in the liSA bC'causc glohal progress a ~ a i n s l (hedisease made il possible 10 d i ~ < . o n t i n u ( roulint vaceinalIOn and othtl protecli\'e anivities. The prt'velll ion ofmeasles by vaccinaTion walt ('stim31t'oI0 have yielded anannual nelSavingofSI30million fOTlheprTlod 1963-1972in Ih('llSA. Th('(urrenl annual ...aving io:;eO:;limated to beapproximalely 5500 million. M e a s 1 t ~ \auination in thelISA io:; ( , ~ I i m a t f d 10 ha\{' a b ( n c f i l - ( o ~ 1 ratio of 10:1. TherClUrn on ~ u c h an in\'eO:;lmenl in the oen'loping- world.where morbidilY and mOTlalil) for m e ~ l c s are higher.would be f'yen grealt'l . A p r ( l i m i n a r ~ anal\sis of vaccineplogram\ in lh e I \'or ) Coasl ~ u g g e s l i the lJt'nefil 10 COSIral io rna well t ~ x c ( r d 20: I.

rhe final queslion co be asked aboul Ihe worldWideC Tadication of measles is the mnO ;I diffinllt-will e do it?Can w(' muSler Ihe social WI)) 10 ellmlnalc another diseasefrom tht ' , odo? A realist ic n ~ w e l i l Ihal, probably, Ihiswill nO I he done for a long timC .\\'hilto \ i e w ~ on measles as a problem differ, its eradicalion is a wonhv,'hile goal. r\ mf'chafllsm for e hit'\'ing Ihis

~ o a l is alread) b,'in/; developed: ,h e \Iobal I:.xpanded Progl am on Immllnilat ion, (oordinal('u by Ihe ' ' 'orld Heall hOrgant/'tsfulh \\'orJ...ing wilhnal ional g o n r n m e n l ~ and intCrnal ional donor agencies 10t l 1 ~ u n : thac immuni7alion againsl five di')east s wil l beroullnel\' 3\ailable Q all the world's C'hildren b) 1990.

The eSlablishment of nadicalion as a goa l migh r a lsohelp 10 slimulale funhrr;:IClion in many (i


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A realistic answer to the question Will we eradicatemeasles? must also consider serious differences betweensmallpox and meas les . Measles is a highly contagiousdisease, capable of causing explosive outbreaks andspreading rapidly. This characteristic contrasts with theepidemiology of smallpox, which generally spreads moreslowly and could be contained by aggressive control measures. This difference between the two diseases suggeststhat an essential ingredient of any measles eradicationprogram would be to attain and maintain extremely highimmunization levels, probably in excess of 90 . Smallpoxwas eradicated by the containment of outbreaks and casesin many areas, bu t the immunity rates of the generalpopulation were often less than 50 . Measles immuniza-tion wil l have to reach children in virtually all parts of acountry simultaneously and successfully.

Another important difference between smallpox andmeasles concerns the age of infection. Smallpox frequently involves children of all ages and adults. In thedeveloping world, the usual age for contracting measles isabout 2 8 months. Measles vaccine cannot be giveneffectively before the s ix th or nin th month of life, andmaximum serum conversion may not occur in some popu-lations until the children concerned are 2 5months old.From this i t would appear that a permanent primary careinfrastructure capable of delivering vaccines routinely tothe majority ofthe population is necessary for theelimina-t ion of measles transmission.

A final major difference is the greater difficulty of surveillance operations for measles compared with those ofsmallpox. Measles is more readily confused with otheillnesses causing rashes, and it does not leave a visible,easily recognized trace such as the scars that helped todetermine who was immune to smallpox. Occasionalserological surveys will be required unless reliable recordsare available, and this will mean additional logistic andlaboratory expenses.

Worldwide measles eradication is worth a special effort.The international publichealth community should strivefor it, bu t the leaders should not hold ou t false promises ofrapid accomplishment. Its achievement will be anothermajor test of will, and failure will be measured by eachcase of measles that occurs. No measles case is inevitable.Each one is a fai lu re of the public health establishment toconvince society that eradication is a feasible goal deserving support.Sou ee Dr. William H. Foege, WOTld Health Forum An Inter-national Journal of Health Development 5 1 ):63-65, 1984

REFERENCES WALSH, ].A. WARREN, K.S. Ne w England Journal of

medicIne 30I :967 1979).2. PUFFER, R.R., SERRANO, C.V. Patterns of MOTtality in

childhood Report of the inteT merican investigation ofmortality in childhood Washington, DC, Pan AmericanHealth Organization, 1973 Scientific Publication No. 262).

ursing responsibilities in immunizationProbably the greatest responsibility of the nurse in

immunization programs is teaching the public the advan-tages of immunization and encouraging widespread participation. In teaching it is advisable to provide informa-tion about diseases, explain why vaccination is desirable,and make sure parents know when it is t ime for the child toreceive additional vaccine doses to be fully immunized.

Persons should be informed of the expected effects aftervaccination and instructed to contact the closest hospitalor health center if any other symptoms develop. The nursemus t expla in tha t the child may have a mild fever, maydevelop a rash, redness , tenderness, swelling and sometimes ulceration at the site of the injection. Generalmalaise and muscle aching for a day or two are also common. Parents should be assured that all these are signswhich show that the vaccine is working and should clearwithin 24 hours.

The diseases which infants and young children can getif immunization is not given are diphtheria, whoopingcough, tetanus, measles, polio, and tuberculosis. f theeffects of these are described to parents in a clear andprecise manner, they may be more apt 10 make sure theirchildren are fully vaccinated. This outline can serve as aguide but the nurse knows the patients best.4

DiseaseDiphtheriaWhooping cough

Pertussis)Tetanus

Lock jaw)Measles

Polio

Tuberculosis

ffectAttacks the throat and causes suffocation, and death.Coughing which causes vomiting,weakness, and distress.Causes painful spasms andrigidity of body muscles. May cause

death.Attacks the whole body. Causes veryhigh fever. cold, sore throat, and arash. After a measles infection, achild may get severe complicationssuch as pneumonia and diarrea andmay lose his appetite and becomemalnourished.t is a very serious disease and maycause parts of the body to becomeparalyzed.May attack any part of the body, butusual ly a tt acks the lung. Causessevere coughing, loss of weight andprogresses to death if not treated.


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Materials

uh lu hi alth euri t ' l f o r t ~ \hould I lCYi {I\i II I t n , , ~ of nonOtlJlChOrf/lhllJ n\ hrat/h tar,. i rd, H un , , I Itli ri {( Hlml. 0,,(JnPt fult h I ll /HIT/ fU l l /Jl ( 1 ( ,I I11 ( 1II , . f l \ lU( 1 \ 1I11 l Io I I :. a l lu l l

,Photu M h nH \ \\ 1101

t',C' a Ihlt,( fOlil. UI four I 2 11Iel (aparil\ prc' un'(uoh'l wil h (I lid Ihal c lamp, or [('Wo; 11110 pO'lI lon 0\ rrlilt' n u l n rim. SUPPOII Lilt, J 1 l ~ H t : r i a l l 10 be s'l ilill'd on a1IH.'Ii.t1 lac J po i,iolll'd ahoul fi c01 .. fr om the bOllom o f t hej)H iUIC rooktT. A r;H k may bt' implo\'i f'c1 t)\ l I ~ l r l g a lill,In ~ I p p i oximall'l} 17.5 (m s in dial1lClt'l, ( lit 10 a ht'iglH 01

ealnl rnl,thod fOl , u r f ~ H t an d t. et'p ~ l e l J I I J l I O I 1 . Tht' lalilpha,e I('''iled Ihe t'ffeCli\t'lwli of Ih(' proccdurt,.

Fxprl ll1lt'JlI d{'nlolHlralrd lhal a dOI11l 5l1c pressure(oolt'l uHdd ind,,('c ra t h Irmp('f,HUre, Ilrcc' ,arv 100(' ' '-t loy hac ill i l ha l f t i i ~ l ( d IOffe t1('al. TIl( (l\'('lage Ieamgt'lu'Jaled hy III t'\' 11I{' (t)olt'I i v : H i ~ . o d hl'I\\'I'I'1l 14.: Ib in 2 I 120. 1C) alld IH II> Ill' ( 121C). dependin , ; on l i l ti l I I t n ~ iI \ of ill


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6 cms. thaI has been perforated on the top with nai l holesabout 0.5 ems In diameter. The-support should be madeofa material that will nm retain water. \-\food. for example. isunacceptable,ProcedurePlace 500 ml of water in Ihe pressure cooker. Use unbleached COllOn 10 wrap the malclials to be slcrili7ed.Place the pack('ls on the rack or improvised support andarrange them in such a way 10 allow steam to freely circulate. They should occupy no morc than 75 of t h t ~ spaceavailable above the support.

Lock the lid of the pressure cooker without pUlling onIhfsafely valve and [Ufn ol1lhe heal. Boillhe , ';:uer Of fi eminutes [0 el iminaI{' POckt'fS of ho t air and UllI i l lhc Slt 'amescapes in a steady flow. Then place Ihesa(ety valve on ,helid. As pressure builds inside fhe cookrr and reaches {helimil for which lhe valve was designed. a whistle is heardas hm steam is rdeased. Lower the burner so Ihal a cantinuous jet of whislling SH- am IS mailllained.

Timf' tht, slerilizaLion f rom this poinl. 15 to 20 minulesfor surface sterilizalion (syringes, needles. Iweezers) and 30minutes for deeper sterilizalion- (gaule, dressings).

\Vhen Ihe sieril ization is complete. Iurn off lhe heal andleave the c l o ~ l c cooker on the stove or on a surface lhal isnOt toO cold (to avoid condensation). AfH'r five minu(('slhe pressure will drop. Remove Ihe safcty valve but leaveon lhe lid for an addilional 10 minutes. Allow lheconlent t10 dry wilh lhe cooker panly opened.

The unblea day lraining courst which covered principles ofslcrili7ation was conducled for five community healthworkers from the area. The procedure was ill ustrated firslwil h slides and instruct ional malerials followed by ademonstrat ion and practice session. Workers also learned 10fabricate' Ihe pt'rforaled baseplale which was (Ul from thebollom of a powdered milk tin.

During the training period and in the weeks whichfollowed. a number of minor difficuhies W('n' encounlen'd. Storing sterili/ed malerial overnighl in Ihe localCflller was found to be unsatisfactory and il was drcidf?dIhat malcrial should be sterilized on lhesame day that it is


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Reported Cases P DiseasesNumber of reported cases of measles poliomyelitis tetanus diphtheria and whooping coughfrom 1 January 1984 to date of last report and for same epidemiological period in 1983 by country

TetanusWhooping

Date Measles Poliomyelitis Non neonatorum Neonatorum Diphtheria CoughSubregion and of lastCountry report 1984 1983 1984 1983 1984 1983 1984 1983 1984 1983 1984 1983

NORTHERN AMERICACanada 01 Dec. 4 050 1 129 2 198United States 01 Dec. 2 499 2 039 2 090

CARIBBEAN Antigua an d BarbucLa . 06 Oct.

Bahamas 03 Nov. 8Barbados 03 Nov.Cuba 11 Aug 58 227Dominica 03 Nov. 1 11Dominican Republic 16 Jun. 7 42 88 151

. Grenada 03 Nov.Haiti 16 Jun. 427 221Jamaica 06 Oct. 26Saint Lucia 01 Sep.

; S t C h r i s t o p h e r N ~ ~ _ L 15 Sep.e St. Vincent an d th eGrenadines 07 Jul. 14 IS. Trinidad an d Tobago 08 Sep. 3 3_ll3ONTINENT L MIDDLE AMERICABelize 01 Dec. 3 1 1Costa Rica 06 Oct. 6 4 128 341 Salvador 08Sep. 3 248 15 48 325 344Guatemala 31 Mar. 868 5 31 28 30 450 297Honduras 03 Nov. 2 853 48 3 13 21 14 448 494Mexico Nicaragua 08Sep. 118 42Panama 03 Nov. 338 3 747 5 5 5 IS 144 66

TROPI L SOUTH AMERICABolivia 21 Apr. 805 I 13 19a 46 438Brazil II Aug 36 694 29 294 34 33 1 313 1 344 372 447 2 254 2 452 ll l88 18 231Colombia Ecuador 16 Jun. 4 188 546 5 43 32 21 35 62 8 195 502Guyana 08 Sep. 187 7Paraguay 03 Nov. 707 945 10 72 62 72 112 9 3 569 207Peru 22 Sep. 2 406 63 189 4 42 2 236Suriname 14 Jul. 21 12 2Venezuela 06 Oct. 7 273 8 327 2 1 163 2 459

TEMPERATE SOUTH AMERICAArgentina 06 Oct. 17 246 2 374 2b 107 b 10 35 10 703 1 963Chile 03 Nov. 3 354 4 668 19 22 119 77 1 059 Uruguay 28 Aug. 28 6 7 1 63 182a21 Aug. N o casesb21 Jul. Data no t available

No 1984 reports received therefore no information is shown for 1983.


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to be used. At first, the flame of the gas burner was found tobe unsteady because a regulating valve had no t been fittedbetween the cylinder and the burner. This was subsequently corrected and the gas flame stabilized. Healthworkers were no t able to accurately time the sterilizationperiod when relying on their own watches because of thehigh level of activity in the center. Clock timers with analarm were therefore introduced.Sterilization by pressure cooker was found to be superio r to boiling water primarily because steam under pressure reaches a higher temperature, bu t also because thepossibility of contaminating cotton-wrapped materials byhandling them a ft er they ha ve been ste ril ized is gr ea tl yreduced. Pressure cooker s te ri li za ti on is p ra ct ic al , economical, without serious difficulties in implementation,and is easily carried ou t at the health facility or at home asw el l a s in rural areas.

Editorial note: Water boils at IOWC at sea level). Athigheraltitudes, as the atmospheric barometric pressure drops,water boils at much lower temperatures. Because of this,boiling is certainly no t an effective means of sterilization.Steam under pressure isfar more reliable. The efficiency ofpressure cookers as sterilizing devices depends on their airtightness. Rubber washer rings attached to the lid t end towear out causing steam leaks and rendering sterilizationineffective. is e ss en ti al , t he re fo re , that those whoconsider this method should have extra rings so that wornout washers can be replaced.

Source: From a paper prepared by Yoriko Kamiyama of SaoPaulo University s Department of Medico-Surgical NursingCare: xperiencesu r l utillsation de marmlte a pre ss ion entant qu autoclave

Revolving und ontr ts set v ine pri es

Prices which will be in effect for the period I January1985 to 31 December 1985 for vaccines purchased underEPr annual contracts are provided below for information.Participants are reminded that a l ea d time of four to six

weeks is n ec es sa ry for d el iv er y once an order has beenplaced with a supplier. To be sure that vaccines arrive intime for immunization activities, it is best to order threemonths before they are needed.

Number Priceof doses per doseVaccine per vial F.O.B. U

DPT 10 doses .02120 doses .016

POLIO 10 doses .02520 doses .0162550 doses .0135MEASLES dose .16

Edmonston dose .215with syringe

MEASLES dose .32 Schwartz) 10 doses .067

10 doses .120w ml syringe

BCG 10 doses .07820 doses .04150 doses .0234

TT 10 doses .013520 doses .010DT 10 doses .014adult 20 doses .014DT 10 doses .018pediatric 20 doses .014

The PI\ ewsletter is published bimonthly. in English and Spanish. by theExpanded Program on Immunization EPI) of the Pan American Health Organization PAHOl. Regional Office for the Americas of the World Health Organization WHO). Its purpose is to facilitate the exchange of ideas and informationconcerning immunization programs in the Region in order to promote greaterknowledge of the problems faced and their possible solutions.References to commercial products and the publication of signed articles inthis newslettn do not constitute endorsement bv PAHO WHO. nor do thevnecessarily represent the policy of the r g a n i z a t i ~ n .Editor: Ciro de QuadrosAssistant Editors: Peter C .arrascoKathryn FitchContributors to this issue:Maureen Anderson, PAHOJacqueline Barth. PAHO

ISSN 0251 4710

Expanded Program on ImmunizationMaternal and Child Health Program _Pan American Health Organization 525 Twenty-third Street, N.W.Washington, D.C. 20037U.S.A.

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