Efficacy of two dose measles vaccination in a community setting.

OBJECTIVE: To compare the efficacy of two dose and single dose measles vaccination in a community setting. DESIGN: Two community ICDS blocks with populations of 8990 and 8550 children below 12 years of age were selected. Block A had 1560 children between 9 mo to 1 year of age and Block B had 1380 children between the age of 9 mo to 1 year. METHODS: All eligible children between 9 mo to 1 year of age were given measles vaccination in October 1994. Only the children in Group A were given a second dose of measles (as MMR) in April 1995; six months after the first dose. A survey was undertaken from January 1996 to April 1996 to clinically evaluate the number of cases of measles in both these blocks. RESULTS: In Block A 3 children developed measles, whereas in Block B, there were 16 cases of measles (p < 0.01). All other parameters in both groups, e.g., cold chain maintenance were similar. CONCLUSION: This study supports the superiority of two dose measles vaccination given at an interval of 6 months over a single dose measles in a community setting.

Reactogenecity of indigenously produced measles vaccine.

OBJECTIVE: To assess the safety and reactogenecity of indigenously produced measles vaccine derived from EZ strain. DESIGN: A longitudinal clinical follow up after vaccination. SETTING: Hospital based and home follow up, as required. SUBJECTS: 12,470 children, 9 to 15 months old, immunized with measles vaccine of EZ strain, in accordance with the National Immunization Schedule, at five centers. METHODS: A clinical follow up of children at 1 day, 1 week, 2 weeks, 3 weeks and 6 weeks after measles vaccination. A detailed clinical neurological examination in children showing side effects. RESULTS: Mild side effects were documented in 31%. Of these, 90% were seen in the first two weeks, out of which two thirds were seen during the first week. Commonest side effects were coryza (10%), fever (9.8%), cough (3.2%) and diarrhea (3.2%). Convulsions, with no later sequelae were documented in 2 cases only. CONCLUSIONS: Measles vaccine manufactured in India, using EZ strain is a safe vaccine. It has a level of reactogenecity including neurological aspects, lower than that reported in India with the Schwarz strain vaccine.

Immunogenicity and reactogenicity of indigenously produced MMR vaccine.

OBJECTIVES: To study immunogenicity and reactogenicity of indigenously produced MMR vaccine and to assess the booster effect of MMR immunization on measles seroconversion. DESIGN: A longitudinal follow up. SETTING: Hospital based and home follow up, as required. SUBJECTS: 89 children already immunized for measles, between 15 to 24 months of age for immunogenic evaluation and 866 subjects for the reactogenic component. METHODS: Prevaccination and postvaccination samples collected one and four weeks after vaccination were studied by ELISA for IgG and IgM antibodies against the three diseases. A clinical follow up of immunized children was done at 3 days, 7 days, 6 weeks and 6 months after immunization. RESULTS: IgG positivity 4 weeks after immunization rose from 75% to 100% for measles, from 12% to 92% for mumps, and from 13% to 99% for rubella. Only mild side effects including pain and swelling in 37 (4.3%) cases, mild fever in 51 (5.9%) cases, cough in 40 (4.6%) cases and a transient rash in 7 (0.8%) cases were observed. CONCLUSIONS: The indigenously manufactured MMR vaccine has an excellent immunogenicity and low reactogenicity with a booster effect for measles seroconversion in children already immunized for this disease.

The expanded programme on immunization: a decade of progress in India.

The Expanded Programme on Immunization (EPI) was initiated in India in 1978 with the objective to reduce morbidity and mortality from diphtheria, pertussis, tetanus, poliomyelitis and childhood tuberculosis by providing immunization services to all eligible children and pregnant women by 1990. Measles vaccine was included when the EPI was accelerated by launching the Universal Immunization Programme (UIP) in 1985-6. Approximately half of all infants now receive complete primary immunization with diphtheria, polio and tetanus (DPT), oral polio vaccine (OPV) and BCG vaccine. Forty-six per cent of pregnant women currently receive a second or booster dose of tetanus toxoid (TT). Surveillance reports from selected areas have documented impact through reduction of disease incidence. Although vaccination coverage levels are increasing, continued acceleration is needed to achieve the universal levels targeted for 1990.

Review of mother and child health programmes and targets in light of the national health policy.

PIP: India has awarded a high priority to increasing the availability and acceptability of maternal-child health services such as immunization, family planning, infant nutrition, and control of diarrhea. To achieve the desired impact, these activities should be targeted at areas of greatest priority--e.g., minimum perinatal care, low birth weight infants, maternal undernutrition, growth of children in the 1st 2 years of life, and acute respiratory infections. Careful attention should be given to identifying those at highest risk, whether for biomedical, social, or economic reasons. Also important are nonprogrammatic activities such as group education, in-service training, curriculum development, and management courses for health workers. Although India has performed quantitative assessments of its maternal-child health program, a qualitative analysis has yet to be performed. This should consist of a critical appraisal of whether quantified objectives have been met. The evaluation process should ensure the desired information is available, verify its relevance, assess its adequacy, and evaluate effectiveness. For such a system to work, valid and reliable information must be generated at the primary level of the health care system and analyzed by a comprehensive systems approach.^ieng

Control of neonatal tetanus in India.

PIP: Neonatal tetanus (NNT), a disease preventable by immunization, is a major problem and a leading cause of neonatal mortality. Sample surveys were organized in 1981 and 1982 by the Directorate General of Health Services in India, in collaboration with the state health authorities, to collect reliable baseline data on NNT. The surveys were carried out by the 30 cluster sampling technique. Rural and urban populations were surveyed separately. The survey was conducted by restrospective house to house visits. In each unit, a sample of 2000 live births was studied; 67 live births being recorded in each cluster. Based on the survey results, it is estimated that 2.3-2.5 lakh infants died within the 1st month of life due to NNT during 1981; nearly 2/3 of these were in Uttar Pradesh. Although the NNT mortality rates varied from state to state, they were consistently higher in the rural areas. Tetanus as a cause of neonatal deaths ranged from 0-68.7% in the urban areas and from 16.4-72.5% in the rural areas. The control of tetanus in general and neonatal tetanus, in particular, is receiving a high priority in the government programs. 2 major programs are in operation for the prevention of NNT in the country -- the immunization of pregnant women with tetanus toxoid vaccine (TT) under the expanded program on immunization (EPI) and the training of dais under the rural health program. NNT will be prevented if the women and the dais (who are still associated with almost 70-75% of the deliveries in many areas with high NNT mortality rates) are convinced of the need for TT vaccination during the antenatal period and practice the basic principles of cutting cord and keeping the umbilical stump free of unclean dressings. The vaccination of pregnant women was started as a national program in 1975-76 with a modest coverage of 14.5 lakhs. The number of pregnant women given either 2 or a booster dose in 1982-83 had risen to 74.0 lakhs. The plan is to cover 110 lakhs pregnant women in 1983-84 and 130 lakhs in 1984-85. Besides the vaccination of pregnant women, TT immunization services are provided to infants and children. Since the protection received from the mother will last only for a few months, infants are given TT as a combined vaccine with diphtheria toxoid and pertussis vaccine (DPT) at 3 months of age. The immunization program is a part of primary health care and the services are provided through the existing health delivery systems. The vaccination services are available at the hospitals, maternal and child health clinics, and dispensaries in the urban areas and in the primary health centers and the subcenters in the rural areas. The effectiveness of the control measures will be evaluated by determining the vaccination coverage of the eligible population and by the documentation of the reduction of NNT mortality rates in the area.^ieng

Integrated approach to maternal and child health and family planning.

PIP: India has been emphasizing the interrelationship between primary health care, maternal and child health, and family planning as the major problem for family welfare. Family welfare has been adopted at the national level by the government. Integration of these 2 components of family welfare maternal and child health (MCH) and family planning has been recognized as a feasible proposition for improving the effectiveness and efficiency of the related services. An integration of these 2 services can lead to an improved acceptance of the family planning, give it credibility, and improve cost effectiveness. India follows a policy of simultaneous and concurrent focus on MCH and family planning which are being treated as the 2 arms of family welfare department. The integration of family planning and MCH can be effected in 2 ways: the structural integration, where a common administrative agency runs the program but the services are delivered through different category of workers; and the process integration where the administration and the lower formations take care of both the components of the family welfare services. The integrated approach raises 2 fundamental issues: how to achieve the integration; and the stage at which a particular component should be emphasized. To analyze the problem, a conceptual model was developed. It consists of 4 elements arranged in a sequential manner, indicating the process, the objectives leading to activities which produce certain results, and these results are reflected by the indicators. A newly married couple wants to have children. The pattern of the family in accordance with the small family norm can be developed by the following objectives: to bring about wanted conceptions; the wanted conceptions to develop into healthy newborns; the wanted newborns to be reared to healthy children; to avoid unwanted births; to regulate the interval between the pregnancies; and to adopt a small family norm. Each of the objectives lead to a series of respective activities which produce specific results. The health outcomes of such an integrated program of family planning and MCH can be considered in 3 categories, namely, effects on: mother's health as illustrated by low maternal mortality and morbidity, an improved nutritional status, and a low incidence of preventible complications of pregnancy; fetal health, a low fetal mortality and stillbirth rate, proper care of the newborn, prevention, and early detection of abnormalities of development; and child health, as shown by reduction in perinatal, neonatal, infant and child mortality, a better health of the infant at birth, and a decreased vulnerability to disease by the children.^ieng

Blood vessels of the twin placenta in relation to zygosity.

The anatomical characteristics of the arteries, veins and arteriovenous relationships, velamentous vessels, and vascular communications in 148 placentae from multiple pregnancies were studied. All features were found to show discordance of varying degrees, irrespective of the twins' zygosity. Singular involvement of one component of the twin placenta by hydramnios or congenital defects, incidence of vascular communications and the anatomical characteristics of the vessels in conjoined twins, acardiac monsters and triplets, and a chromosomal discordance in a MZ pair, lend additional support to the initial surmise of anatomical characteristics of fetal blood vessels of the placenta being determined by functional demands. It is suggested that the inequalities of prenatal environment be assessed by an examination of the fetal blood vessels of the placenta before drawing homologies in the twin concordance studies.

Vascular anastomoses in twin placentae and their recognition.

166 placentae from multiple pregnancies (including three triplets and 17 monochorral) have been studied by injection corrosion technique, using cellulose acetate buterite in acetone, under continuous pressure within physiological limits. It has been shown that vascular anastomoses in twin placentae are usually multiple. The direct type is frequently found in monochorial twin placentae and is mostly arterial or venous in nature. The indirect type is observed more commonly in dichorial twin placentae and is mostly arteriovenous in nature. Both types are almost universally found in monochorial monoamniotic placentae. The presence of direct anastomotic channels has a highly significant association with the incidence of marginal vessels and an exaggeration of parameters of stress to an abnormal quantum--both singly and in combinations of three or more-, and is independent of the pattern of branching. In the ontogenetic time-sequence perspective, direct anastomoses, marginal vessels and parameters of stress in a twin placenta can be regarded as different phases of the sequelae of an altered vascular relationship caused by disturbances in the vicinity of the 12th week of gestation. It has been further shown that direct vascular anastomoses are a greater risk to the twins than indirect ones. The importance of early and timely recognition of such channels, by an examination of twin placentae for the presence of marginal vessels, is stressed.