Diphtheria in the Dominican Republic: reduction of cases following a large outbreak / Difteria en la República Dominicana: reducción de casos tras un extenso brote epidémico

OBJECTIVE: To describe the most recent outbreak of diphtheria in the Dominican Republic and the disease's occurrence and vaccination coverage in 2004-2013. METHODS: Clinical data of diphtheria cases that occurred in 2004 and that met the study's case definition were reviewed along with socioeconomic and epidemiological information from the cases' families. Univariate and multivariate analyses were performed to assess risk factors for fatal diphtheria. Routine surveillance and vaccination coverage data are presented. RESULTS: From January 2004-April 2005, a total of 145 diphtheria cases were reported; 80 (66%) of the 122 cases reported in 2004 met the case definition; 26 were fatal (case-fatality rate: 32.5%). Incidence was highest in the group 1-4 years of age at 5.3 per 100 000; 62.5% were male. Of the 80 cases, 61 (76%) where hospitalized in Hospital A, 17 in Hospital B, and 2 in two other hospitals. Earlier onset (first half of 2004), birth order, and tracheotomy were associated with fatal diphtheria (P < 0.05); cases in Hospital A were also more likely to be fatal (P = 0.066). The average annual diphtheria incidence was 4.91 cases/1 million people in 2000-2003, climbed to 8.8 cases per million in 2004-2005, and dropped to 0.38 in 2006-2014; no diphtheria cases have been reported since 2011. DTP3 vaccination coverage ranged from 72%-81% in 2000-2004 and from 81%-89% in 2005-2013. CONCLUSIONS: The 2004-2005 diphtheria outbreak in the Dominican Republic resulted in important and avoidable morbidity and mortality. Annual cases declined and no cases have been reported in recent years. Maintaining high vaccination coverage and diligent surveillance are crucial to preventing diphtheria outbreaks and controlling the disease.

OBJETIVO: Describir el brote epidémico más reciente de difteria en la República Dominicana, la incidencia de la enfermedad y la cobertura de la vacunación del 2004 al 2013. MÉTODOS: Se analizaron los datos clínicos de los casos de difteria acaecidos en el 2004 y que cumplieron con la definición de caso del estudio, junto con la información socioeconómica y epidemiológica de las familias en las que aparecieron los casos. Se llevaron a cabo análisis de una sola variable y de múltiples variables para evaluar los factores de riesgo de difteria mortal. Se presentan los datos de vigilancia ordinaria y cobertura vacunal. RESULTADOS: De enero del 2004 a abril del 2005, se notificaron un total de 145 casos de difteria; 80 (66%) de los 122 casos notificados en el 2004 cumplieron con la definición de caso; 26 fueron mortales (tasa de letalidad por caso: 32,5%). La incidencia más alta (5,3 por 100 000) se produjo en el grupo de 1 a 4 años de edad; 62,5% fueron varones. De los 80 casos, 61 (76%) se hospitalizaron en el Hospital A, 17 en el Hospital B, y 2 en otros dos hospitales. La aparición más temprana (primera mitad del 2004), el orden de nacimiento y la traqueotomía se asociaron con difteria mortal (P < 0 ,05); la probabilidad de evolución mortal fue mayor en los casos ingresados en el Hospital A (P = 0,066). La incidencia promedio anual de difteria fue de 4,91 casos por millón de personas del 2000 al 2003, ascendió a 8,8 casos por millón durante los años 2004 y 2005, y descendió a 0,38 del 2006 al 2014; no se han notificado casos de difteria desde el 2011. La cobertura de la vacunación con DTP3 varió de 72 a 81% del 2000 al 2004 y de 81 a 89% del 2005 al 2013. CONCLUSIONES: El brote epidémico de difteria de los años 2004 y 2005 en la República Dominicana ocasionó una importante morbimortalidad prevenible. Se produjo un descenso en la incidencia de casos y no se han notificado nuevos casos en los últimos años. El mantenimiento de una alta cobertura vacunal y de una vigilancia eficiente es crucial para la prevención de los brotes epidémicos de difteria y el control de la enfermedad.

Introducción de la vacuna conjugada contra Hib en Chile y Uruguay / Introducing Hib conjugate vaccine in Chile and Uruguay

In some countries, the invasive disease caused by Haemophilus influenzae type b (Hib) has been practically eliminated thanks to vaccination. However, in much of the developing world, meningitides and pneumonias caused by these bacteria continue to be a major cause of childhood morbidity and mortality, as well as high hospitalization costs. Because safe and effective conjugate vaccines are now available, the Special Program for Vaccines and Immunization of the Pan American Health Organization has recommended introducting them into the regular vaccination regimen of as many countries as possible. This has been done in Chile and Uruguay, where the Hib vaccine now forms part of the regular vaccination routine. When the vaccine was being introduced, both countries had difficulties they could have avoided if they had known of the experiences of other nations. Therefore, these two countries now offer the lessons they learned to other nations considering introducing the vaccine into their immunization programs. The most important lessons were to: strengthen the epidemiological surveillance system sufficiently in advance of introducing the vaccine; with the support of scientific societies, present the technical information that justifies introducing the vaccine; seek community baking and acceptance; precisely establish in advance the presentation and dosage of the vaccine that is most appropriate for the country; and be certain to have the political and legal decisions needed to ensure the continuity of Hib vaccination in the future

Avaliaçäo do Sistema de Vigilância Epidemiológica do Sarampo nos Estados de Säo Paulo e Bahia / Assessment of epidemiological surveillance of measles, in Säo Paulo and Bahia states

O sucesso da erradicação da transmissão autóctone do vírus da poliomielite nas Américas, levou os Ministros da Saúde dos países membros da Organização Pan-Americana da Saúde - OPAS a assumirem, em 1994, a meta de eliminação do sarampo até o ano 2000. O Plano de Eliminação do Sarampo inclui as estratégias: imunização das crianças de 9 meses a 14 anos de uma só vez e a manutenção de altas coberturas vacinais em menores de 1 ano; campanhas periódicas a cada 2 a 4 anos para menores de 4 anos; a implementação dos sistemas de vigilância epidemiológica, para detectar casos suspeitos de sarampo. O impacto das ações adotadas em vários países da América caracterizou-se pela drástica redução da incidência da doença, estimulando a OPAS a realizar uma avaliação, visando conhecer a verdadeira situação epidemiológica da doença e a capacidade dos sistemas de vigilância epidemiológica em detectar casos/surtos oportunamente e aplicar as medidas de controle de forma ágil. A metodologia, desenvolvida pela OPAS, é de caráter qualitativo com componentes quantitativos. Apresenta-se neste trabalho a avaliação realizada no Brasil nos Estados de São Paulo e Bahia. Os resultados apontam para um sistema de vigilância moroso, que não permite a detecção oportuna de casos ou surtos e que o Plano de Eliminação não representava prioridade política nos anos posteriores a sua implementação em 1992.

The successful eradication of the transmission of autochthonous wild poliomyelitis virus in the Americas, encouraged the Ministers of Health of the members States of the Pan-American Health Organization - PAHO - in 1994 to adopt the goal of eliminating measles in the Region by the year 2000. The Measles Elimination Plan consist of four basic strategies: a one time vaccination of all children between 9 months and 14 years in national campaign; maintenance of high vaccination coverages in children less than 1 year; periodic vaccination campaigns, every 2/4 years to detect suspected cases of measles in children less than 4 years and the implementation and strengthening of epidemiological surveillance system. A drastic reduction in the incidence of the disease was observed in the Americas which stimulated PAHO, to carry out an evaluation of the measles epidemiological surveillance system with the objective to determine the true epidemiological situation and the system's capacity in to detect suspected cases of measles or outbreaks and implement control measures in a timely fashion. The methodology was developed by PAHO, and consists mainly on qualitative attributes with quantitative components. The evaluation was realized in the Brazilian States of Bahia and São Paulo and revealed that the measles surveillance system is slow, not allowing the timely detection of cases or outbreaks and that the Elimination Plan was not considered a political priority in the years following its implementation in 1992.