A review of immunization legislation for children in English- and Dutch-speaking Caribbean countries / Revisión de los marcos legislativos sobre vacunación infantil en países de habla inglesa y neerlandesa del Caribe / Revisão da legislação relativa à imunização em crianças nos países do Caribe de língua inglesa e holandesa

ABSTRACT Objective. To assess the legislative frameworks concerning childhood vaccination in the English- and Dutch-speaking Caribbean and propose a model legislative framework for Caribbean countries. Methods. This study included a survey of 22 countries and territories in the Caribbean regarding legal vaccination mandates for school entry, budget allocations, sanctions, or exemptions. A legal consultant conducted a comprehensive search and analysis of legislation regarding vaccination among 13 Caribbean countries/territories. A comparative analysis of the legislation under five themes—legislative structure, mandatory vaccination, national immunization schedule, sanctions, and exemptions—formed the basis for the proposed model legislation. Results. Among the 22 Caribbean countries/territories, 17 (77%) had legislation mandating vaccination, 16 (94%) mandated vaccination for school entry, 8 (47%) had a dedicated budget for immunization programs, and 13 (76%) had no legislated national schedules. The source of legislation includes six (35%) using the Education Act, eight (47%) the Public Health Act, and five (29%) a free-standing Vaccination Act. Three countries/territories—Jamaica, Montserrat, and Saint Lucia—had immunization regulations. In 12 (71%) of the 17 countries with legislation, sanctions were included, and 10 (59%) permitted exemptions for medical or religious/philosophical beliefs. Conclusions. Several countries in the Caribbean have made failure to vaccinate a child an offense. By summarizing the existing legislative frameworks and approaches to immunization in the Caribbean, the analysis guides policymakers in making effective changes to immunization legislation in their own countries.

RESUMEN Objetivo. Evaluar los marcos legislativos relativos a la vacunación infantil en el Caribe de habla inglesa y neerlandesa y proponer un modelo de marco legislativo para los países del Caribe. Métodos. En este estudio se incluyó una encuesta en 22 países y territorios del Caribe sobre los requisitos legales de vacunación para el ingreso escolar, asignaciones presupuestarias, sanciones o exenciones. Un consultor jurídico realizó una búsqueda y un análisis exhaustivos de la legislación relativa a la vacunación en 13 países y territorios del Caribe. Un análisis comparativo de la legislación dividido en cinco temas (estructura legislativa, vacunación obligatoria, calendario nacional de vacunación, sanciones y exenciones) formó la base del modelo de legislación propuesto. Resultados. Entre los 22 países y territorios del Caribe, 17 (77%) contaban con leyes sobre vacunación obligatoria, 16 (94%) exigían la vacunación para el ingreso escolar, 8 (47%) tenían un presupuesto dedicado a los programas de vacunación y 13 (76%) no disponían de calendarios nacionales estipulados por ley. Entre las fuentes de la legislación, seis países y territorios (35%) empleaban la ley de educación, ocho (47%) la ley de salud pública y cinco (29%) una ley independiente de vacunación. Tres países y territorios —Jamaica, Montserrat y Santa Lucía— disponían de regulaciones sobre vacunación. Doce (71%) de los 17 países con legislación tenían sanciones y 10 (59%) permitían exenciones por creencias médicas o religiosas o filosóficas. Conclusiones. Varios países del Caribe han tipificado como delito el no vacunar a un niño o niña. Al resumir los enfoques y marcos legislativos existentes para la vacunación en el Caribe, este análisis ofrece orientaciones a los responsables de formular las políticas para que realicen modificaciones efectivas en la legislación relativa a la vacunación en sus propios países.

RESUMO Objetivo. Avaliar as estruturas da legislação relativas à vacinação em crianças no Caribe de língua inglesa e holandesa e propor um modelo de legislação para os países caribenhos. Métodos. Este estudo incluiu uma pesquisa relativa à exigência legal em 22 países e territórios do Caribe de vacinação para admissão em escolas, alocações orçamentárias, sanções ou isenções. Um consultor jurídico realizou ampla pesquisa e análise da legislação relativa à vacinação em 13 países/territórios do Caribe. Uma análise comparativa da legislação referente a cinco temas - estrutura legislativa, vacinação obrigatória, cronograma nacional de imunização, sanções e isenções - formou a base para o modelo de legislação proposto. Resultados. Entre os 22 países/territórios caribenhos, 17 (77%) tinham legislação que exigia a vacinação; em 16 (94%), a vacinação era obrigatória para admissão na escola; 8 (47%) tinham orçamento exclusivo para programas de imunização; e em 13 (76%), a legislação não contemplava cronogramas nacionais. Com relação à fonte da legislação, seis (35%) países usavam a legislação de educação; oito, (47%) a Legislação de Saúde Pública; e cinco (29%), legislação de vacinação independente. Três países/territórios - Jamaica, Montserrat e Santa Lúcia - tinham regulamentações para imunização. Dos 17 países com legislação, 12 (71%) incluíam sanções e 10 (59%) permitiam isenções por crenças médicas ou religiosas/filosóficas. Conclusões. Diversos países do Caribe estabelecem que não vacinar uma criança é violação da lei. Ao resumir as estruturas de legislação existentes e as abordagens da imunização no Caribe, a análise orienta os formuladores de políticas a realizar mudanças efetivas na legislação de imunização em seus próprios países.

The Expanded Program on Immunization in the English- and Dutch-speaking Caribbean (1977-2016): reasons for its success / Programa Ampliado de Inmunización en el Caribe de habla inglesa y holandesa (1977-2016): las razones de su éxito / Programa Ampliado de Imunização nos países do Caribe de língua inglesa e holandesa (1977-2016): motivos para um programa bem-sucedido

ABSTRACT The year 2017 marks the 40th year of the establishment of the Expanded Program on Immunization (EPI) by the Pan American Health Organization (PAHO), the regional office of the World Health Organization (WHO) in the Americas, the first WHO region certified as eliminating poliomyelitis (1994), measles (2016), and rubella and congenital rubella syndrome (CRS) (2015). The English- and Dutch-speaking Caribbean subregion of the Americas paved the way in eliminating these diseases. This report highlights the innovative strategies used in this subregion that helped make the EPI a success. A review of published/unpublished reports and written and oral accounts of the experiences of Immunization Advisors and national EPI managers was conducted to identify the strategies used to strengthen the Immunization program in the subregion since its implementation by countries in 1977. The results show that these include strong collective political commitment, country-specific immunization legislation, joint use of a standard coverage monitoring chart, annual meetings of national EPI managers, collaborative development of annual national Plans of Action for Immunization, coordinated implementation of vaccination campaigns, subregional oversight of surveillance and laboratory support, a performance award system for countries, and subregional standardized templates for immunization manuals and procedural guidelines. Political will and support for immunization has been particularly strong in this subregion, where 99% of EPI costs are borne by governments. Dedicated health staff and multi-country agreement and application of strategies have led to high sustained coverage and good-quality surveillance, resulting in the absence of wild polio for 34 years, measles for 25 years, CRS for 17 years, and rubella for 15 years.

RESUMEN En el 2017 se celebra el cuadragésimo año de la instauración del Programa Ampliado de Inmunización (PAI) por la Organización Panamericana de la Salud (OPS), la Oficina Regional de la Organización Mundial de la Salud (OMS) para las Américas. Esta fue la primera región de la OMS que obtuvo la certificación de la eliminación de la poliomielitis (1994), el sarampión (2016) y la rubéola y el síndrome de rubéola congénita (2015). La subregión de habla inglesa y holandesa del Caribe en las Américas abrió el camino a la eliminación de estas enfermedades. En el presente artículo se destacan las estrategias innovadoras utilizadas en esta subregión que contribuyeron al éxito del PAI. Se llevó a cabo una revisión de los informes publicados e inéditos y de los relatos escritos y orales de las experiencias de los Expertos en Inmunización y los gerentes nacionales del PAI con el objeto de determinar las estrategias utilizadas con miras a fortalecer el programa de vacunación en la subregión, desde su introducción en los países en 1977. Los resultados ponen de manifiesto que los programas comportaban un fuerte compromiso político colectivo, legislaciones en materia de inmunización propias de cada país, la utilización común de un registro gráfico normalizado de monitoreo de coberturas de vacunación, reuniones anuales de los gerentes nacionales del PAI, la elaboración conjunta de planes de acción anuales nacionales sobre vacunas, la ejecución coordinada de campañas de vacunación, la supervisión de la vigilancia y el apoyo a los laboratorios a escala subregional, un sistema de reconocimiento al desempeño de los países y plantillas subregionales normalizadas de los manuales de vacunación y los procedimientos recomendados. La voluntad política y el apoyo a la vacunación han sido muy sólidos en esta subregión, donde los gobiernos sufragan 99% de los costos del PAI. La existencia de personal sanitario dedicado y los acuerdos multinacionales y la aplicación de las estrategias permitieron alcanzar una alta cobertura de manera sostenida y una vigilancia de buena calidad, cuyo resultado fue la ausencia de poliomielitis salvaje durante 34 años, de sarampión durante 25 años, del síndrome de la rubéola congénita durante 17 años y de la rubéola durante 15 años.

RESUMO O ano de 2017 marca o 40° aniversário da criação do Programa Ampliado de Imunização (PAI) pela Organização Pan-Americana da Saúde (OPAS), Escritório Regional da Organização Mundial da Saúde (OMS) nas Américas, primeira Região da OMS certificada como tendo eliminado a poliomielite (1994), o sarampo (2016) e a rubéola e síndrome da rubéola congênita (2015). A sub-região das Américas constituída pelos países do Caribe de língua inglesa e holandesa abriu caminho ao eliminar essas doenças. Este relato destaca as estratégias inovadoras usadas nesta sub-região que contribuíram para tornar o PAI um programa bem-sucedido. Foi realizada uma análise de informes publicados/inéditos e relatos orais e escritos da experiência dos assessores para assuntos de imunização e coordenadores nacionais do PAI visando identificar as estratégias aplicadas para consolidar o programa nos países da sub-região desde a sua implementação em 1977. Os resultados demonstram firme compromisso político coletivo, legislação de vacinação própria em cada país, uso conjunto de uma lista padrão para o monitoramento da cobertura, reuniões anuais dos coordenadores nacionais do PAI, desenvolvimento colaborativo de planos de ação nacionais anuais para vacinação, campanhas coordenadas de vacinação, supervisão sub-regional da vigilância e infraestrutura laboratorial, sistema de premiação dos países por bom desempenho, modelos padronizados para os manuais de vacinação e protocolos de procedimentos. A sub-região se caracteriza sobretudo pela vontade e apoio políticos para vacinação, sendo 99% do custo do PAI financiados pelos governos. Equipes de saúde diligentes, acordos entre vários países e emprego de estratégias são fatores que contribuem para elevada cobertura sustentada e vigilância de boa qualidade com a consequente não ocorrência de casos de poliomielite por vírus selvagem por 34 anos, de casos de sarampo por 25 anos, de casos de síndrome da rubéola congênita por 17 anos e de casos de rubéola por 15 anos.

Absence of impact of aerial malathion treatment on Aedes aegypti during a dengue outbreak in Kingston, Jamaica

During an outbreak of dengue fever in Jamaica from October to December 1995, a study was carried out to determine the impact of aerial ultra-low volume malathion treatment on adult Aedes aegypti. This was done by monitoring oviposition rates of the vector in three urban communities in Kingston and by exposing caged mosquitoes both directly and inirectly to the aerial malathion treatment. The insecticide was delivered at a rate of 219 mL/ha between 7:10 a.m. and 8:45 a.m. The results of the study clearly showed that the insecticide application was ineffective in interfering with Aedes aegypti oviposition, and adult mosquitoes held in cages inside dwellings were largely unaffected. Consequently, this type of intervention seemed to have little significant impact in arresting or abating dengue transmission

A comparison of prevalence rates of genital ulcers among persons attending a sexually transmitted disease clinic in Jamaica

Two cross-sectional surveys were undertaken, from December 1982 to August 1983 and from November 1990 to January 1991, to estimate the prevalence rates of genital ulcer disease (GUD) in all patients presenting with a new sexually transmitted disease (STD) complaint to the STD clinic at the Comprehensive Health Centre in Kingston, Jamaica. Diagnosis of syphilis and human immunodeficiency virus (HIV) infection was based on results of laboratory tests, but diagnosis of other STDs was based on clinical features. Data from these two surveys were compared, and reported national annual incidence data for GUD reviewed. In 1982/83 6.8 percent of 23,050 patients had GUD, men (9.3 percent) more often than women (4.2 percent; p < 0.001). In 1990/91 the prevalence rate was 12.8 percent with increased rates for both men (18.2 percent) and women (6.8 percent; p < 0.001). In patients with GUD, a clinical diagnosis of genital herpes was made, in 1982/83 and 1990/91, respectively, in 16.8 percent and 7.8 percent of the patients; syphilis, in 12.9 percent and 18.8 percent; chancroid, in 12.4 percent and 13.3 percent; viral warts, in 5.7 percent and 6.3 percent; lymphogranuloma venereum, in 4.1 percent and 3.9 percent; and granuloma inguinale, in 3.6 percent and 2.3 percent. In men the rate for syphilis was 19 percent in 1990/91 and 8 percent in 1982/83 (p=0.001); and for genital herpes it was 7 percent in 1990/91 and 17 percent in 1982/83 (p=0.025). These reversals were attributed to intense media coverage of herpes in 1982/83. There was no difference in prevalence rates between the two surveys for these diseases in women, or for lymphogranuloma venereum, granuloma inguinale and genital warts in men and women. A clinical diagnosis could not be made in 44.4 percent of cases in 1982/83 (particularly in men), and in 47.6 percent of cases in 1990/91. GUDs faciltate transmission and adversely affect the prognosis of HIV. The increase in their prevalence has implications for the evolution of the local HIV epidemic, and hould be addressed effectively by stregthening the STD/HIV control programme.

Survey of patients with sexually transmitted diseases seen by private physicans in Jamaica

A survey of physicians in private practice in Jamaica was conducted between March and September 1993 to provide a descriptive analysis of the occurrence of patients with sexually transmitted diseases (STDs) seen in their practices. Questionnaires were delivered to 371 physicians of whom 127 (34 percent) responded, completing 683 (men 353, women 330) individual patient questionnaires. Each physician collected data over a period of one week. The median ages of the men and women were 27 years and 26 years, respectively. 464 (68 percent) patients were being seen for the first time for symptomatic STDs, and the visit was a follow-up for 132 (19 percent) who had been previously diagnosed; 40 (6 percent) patients were asymptomatic contacts referred by a sex partner, and 12 (2 percent), who were asymptomatic, asked for a "check up". A history of previous STD was given by 358 (52 percent) patients. 470 (69 percent) patients had a genital discharge (M, 65 percent; F, 73 percent; p = 0.017), 52 (8 percent) had anogenital lesions (M, 10 percent; F, 5 percent; p = 0.013) and 45 (7 percent), inguinal lymphadenopathy (M, 10 percent; F, 3 percent; p = 0.002). Among women, 131 (40 percent) had lower abdominal pain on examination and 105 (32 percent) had cervical excitation tenderness or pain suggesting pelvic inflammatory disease (PID). A working diagnosis of gonorrhoea was made in 273 (40 percent) patients, trichomoniasis in 121 (18 percent), nongonococcal infection in 114 (17 percent), syphilis in 60 (9 percent), herpes genitalis in 20 (3 percent) and chancroid in 11 (2 percent). PID was diagnosed in 121 (37 percent) women and nongonococcal urethritis in 98 (28 percent) men. The most frequently prescribed treatments were for chlamydia, gonorrhoea and trichomoniasis. In general, working diagnoses correlated well with clinical observations and treatment given, matched with diagnosis according to national guidelines. A comparison of the STD burden between the public and private sectors was not possible because of sample bias.

Is under-reporting of AIDS a problem in Jamaica?

A survey of physicians in Jamaica was conducted between March and September, 1993 in order to estimate the level of reporting of HIV and AIDS. A questionnaire was delivered to nearly all of approximately 1,200 physicians practising in Jamaica. Completed questionnaires were received from 518, a response rate of 35 per cent. Of the physicians responding, 46 per cent were in private practice only, 22 per cent in the public sector only and 32 per cent in both. Two-thirds (66 per cent) of the physicians in private practice had not diagnosed a case of AIDS and 65 had not had a patient with a positive HIV test result. Half (54 per cent) of the private physicians had reported all their AIDS cases, 8 per cent had reported some and 38 per cent (45 doctors) had reported none. The main reasons for not reporting were: "thought someone else had reported" (15 doctors), concern for confidentiality (11) and not knowing where to report (8). Only 9 per cent of private practitioners were currently seeing an AIDS patient and 12 per cent were seeing an HIV-infected person. Of physicians with current AIDS patients 16 per cent preferred not to report, 21 per cent intended to report and 63 per cent had reported. Nearly one-third (29 per cent) of private practitioners expressed reservations about treating persons with HIV/AIDS. Most (75 per cent) public sector physicians had seen one or more AIDS patients. Sixty-four per cent of these physicians said that all of their AIDS cases were reported, 4 per cent said some, 4 per cent said none and 28 per cent didn't know. Reporting of AIDS cases is better in the public sector than among private physicians. It is likely that some, if not many, of the AIDS cases not reported by private physicians are reported when admitted to hospital. It is not possible to estimate the precise level of under reporting of AIDS in Jamaica from this survey. However, more needs to be done to address the reservations of some private physicians and convince them of the need for timely reporting of HIV/AIDS cases

A survey of hepatitis B among health workers in Jamaica

One thousand, five hundred and thirty-seven health staff, presenting for hepatitis B vaccination in Jamaica, were surveyed in 1990/91 for hepatitis B markers and/or expose to blood or hepatitis. Antibodies to either hepatitis B surface antigen (HBsAg) or hepatitis B core (HBc) were found in 19.8 por ciento of 817 persons tested. Males were more likely to have antibodies to Hepatitis B Virus (HBV) than females (29 por ciento compared with 18 por ciento , Odds Ratio 1.6;95 por ciento CI 0.98-2.9). HBsAg was found in 5.3 por ciento of 562 persons tested compared with 1 por ciento of blood donors. One or more needlestick accidents were reported by 60 por ciento of the sample, and blood or liquid splashing on the face was reported by 48 por ciento . Jaundice and hepatitis were reported by 1.2 por ciento and 3.5 por ciento of health staff, respectively. HBaAg carrier status was associated with years of service (p=0.039). Prevalence of antibodies to HBV increased withe age (p=0.004) and years of service (p=0.028). The effect of age and years of service appears to be largely independent (r=0.44). this survey reaffirms the importance of health workers being immunized with hepatitis B vaccine, and adhering rigorously to universal precautions in patient care and laboratory practice.

An evaluation of perinatal services in institutions in Jamaica

An evaluation of perinatal services in institutions was undertaken as part of the perinatal morbidity and mortality survey of Jamaica 1986-1987. Observations were made of obstetric practice and immediate neonatal care on five randomly selected days during September and October 1986 using a standard questionnaire based on the WHO guidelines on appropriate technology for birth. Of 140 deliveries 18 per cent (95 per cent CI 12 per cent - 25 per cent) were unattended (i.e. head not controlled on the perineum). Median bed utilisation was 68 per cent with a range of 0 - 93 per cent. Thirty-five per cent of institutions had maternity beds with more than one patient to a bed. Only 7 per cent of babies were put to the breast immediately following delivery and 47 per cent within two hours. Eighty-four per cent of newborns received adequate cord care. There was a shortage of nursing staff with 53 per cent, 77 per cent, 82 per cent, and 86 per cent of registered nurses and midwifery posts filled at CRH, VJH, Spanish Town Hospital and UHWI respectively. The findings indicate the need for immediate measures to improve the standard of care.

An evaluation of the domiciliary midwifery services in Jamaica

A random sample of 78 district midwives, representing 24 por ciento of all district midwives in the government health service, were interviewed to assess their knowledge and practice of domiciliary midwifery as part of the Jamaican Perinital Morbidity and Mortality Survey in 1986. A standard questionnaire based on the WHO guidelines on appropriate technology for birth was used. Records of their preceding home deliveries were examined and their delivery bags inspected for availability of basic supplies and equipment. A mean of 21.5 home deliveries were attended by each rural midwife in 1986 compared with 3.8 in the urban areas. Routine laboratory were not done on many mothers and there were long delays in getting results. Midwives' knowledge was average overall with one third of them showing poor knowledge of high risk factors in infants and newborn care. Most midwives routinely shave and give enemas to mothers. Unavailability of equipment and supplies, including vitamin K and eye drops, is common. 24 por ciento of midwives made no prenatal home visit in the previous month and 80 por ciento fell short of the set norm of 5 postnatal home visits. 84 por ciento of midwives put the baby to the mother's breast within one hour of delivery. Essential supplies and lab investigations need to be provided and measures taken to improve domiciliary midwifery through a programme of continuing education and better supervision of midwives. A strategy to promote home deliveries under specified conditions needs to be considered.

A simple method for evaluating perinatal services in developing countries

This paper examines the methodology that was developed in the service component of the Perinatal Morbidity and Mortality survey of Jamaica 1986-1987. Using WHO guidelines of appropriate technology for birth, questionnaires were developed to evaluate institutional and field midwifery services as well as to prepare an inventory of staff, basic equipment and supplies. All public maternity institutions in Jamaica were assessed by direct observation on 5 randomly chosen days. Also a 25 por ciento random sample of district midwives were interviewed and their delivery bags and notes inspected. The methodology enables important observations to be made concerning the quality of perinatal care but does not measure health outcome. The methodology is simple, flexible, useful for planning and monitoring standards of care and may be adapted for use in other developing countries.