An assessment of safe injection practices in health facilities in Swaziland.

OBJECTIVES: To determine the magnitude and causes of unsafe injection practices in Swaziland. DESIGN: A safe injection practices questionnaire was administered and injection practice was observed. SETTING: A selected variety of health facilities in Swaziland. SUBJECTS: Health workers in each facility. OUTCOME MEASURES: Unsafe injection and collection for disposal practices. RESULTS: All injections observed involved disposable syringes. Although all injections were given at the correct site, using the correct dosage and equipment, unsafe injection technique was observed. Needles were changed on the same syringe at 8 facilities (31%) and syringes and needles were reused at 2 facilities (8%). Recapping of needles after use occurred at 8 facilities (31%). More than one-quarter of nurses reported having pricked their finger in the previous 6 months; in almost half of these cases this was after administration of an injection. Seven nurses (25%) recalled seeing a case of an abscess or a mild adverse event following an injection in the previous 12 months. Interviewers observed used syringes and needles being placed in a safe container in three-quarters of facilities. Almost all respondents reported that syringes and needles were buried or burned. CONCLUSIONS: Auto-disable syringes should be used for all routine and supplemental vaccination. The increased cost of auto-disable syringes represents only a small increase in the national Expanded Programme on Immunisation (EPI) budget.

Missed opportunities for vaccination in health facilities in Swaziland.

OBJECTIVES: To determine whether potential exists to increase vaccination coverage in Swaziland by reducing missed opportunities. DESIGN: The standard World Health Organisation Expanded Programme on Immunisation (WHO EPI) protocol for assessing missed opportunities for vaccination was used to conduct this study. It involved client exit interviews and review of health cards. SETTING: Selected variety of health facilities in Swaziland. SUBJECTS: Children less than 2 years of age and women of child-bearing age exiting each facility. OUTCOME MEASURES: Children and women eligible for vaccination exiting sampled health facilities. RESULTS: Fifty-four per cent of eligible children less than 2 years of age were missed for vaccination. This constitutes 26% of all children less than 2 years old leaving the facilities studied. Almost 100% of eligible women of childbearing age were missed for vaccination, constituting 88% of women leaving the study facilities. The distribution of the proportion of missed opportunities varied considerably between regions and health facility types. Missed opportunities occurred more frequently among those children requiring the first dose of all antigens and this may be linked to the high proportion of children missed for vaccination who did not possess a health card. Missed opportunities were more likely to occur in facilities providing integrated services. CONCLUSIONS: The frequent attendance at health facilities of the target group presents a valuable opportunity to increase vaccination coverage through avoidance of missed opportunities. All regions need to set vaccination coverage targets and develop plans to increase coverage, which should include strategies to ensure that all health workers routinely screen all clients for eligibility and vaccinate as required.

Estrategias para reducir a un mínimo la transmisión nosocomial del sarampión / Strategies for minimizing nosocomial measles transmission

Como resultado de la gran contagiosidad del sarampión antes de salir la erupción, la transmisión nosocomial seguirá siendo un peligro hasta que se erradique la enfermedad. No obstante, varias estrategias pueden reducir a un mínimo la transmisión nosocomial. Es imprescindible, por lo tanto, hacer que el personal de salud cobre mayor conciencia de que un individuo con sarampión puede llegar en cualquier momento a un servicio de salud y de que el peligro de transmisión del sarampión en el medio hospitalario existe de continuo. La presente revisión contiene dos grupos de recomendaciones: las que suelen ser aplicables a todos los países, y ciertas recomendaciones adicionales que pueden ser apropiadas solamente para países industrializados

Estrategias para reducir a un minimo la transmisión nosocomial del sarampión / Strategies for minimizing nosocomial measles transmission

Como resultado de la gran contagiosidad del sarampión antes de salir la erupción, la transmisión nosocomial seguirá siendo un peligro hasta que se erradique la enfermedad. No obstante, varias estrategias pueden reducir a un mínimo la transmisión nosocomial. Es imprescindible, por lo tanto, hacer que el personal de salud cobre mayor conciencia de que un individuo con sarampión puede llegar en cualquier momento a un servicio de salud y de que el peligro de transmisión del sarampión en el medio hospitalario existe de continuo. La presente revisión contiene dos grupos de recomendaciones: las que suelen ser aplicables a todos los países, y ciertas recomendaciones adicionales que pueden ser apropiadas solamente para países industrializados

[Strategies for minimizing nosocomial transmission of measles]. / Estrategias para reducir a un mínimo la transmisión nosocomial del sarampión.

Because of the highly contagious nature of measles before the onset of rash, nosocomial transmission will remain a threat until the disease is eradicated. However, a number of strategies can minimize its nosocomial spread. It is therefore vital to maximize awareness among health care staff that an individual with measles can enter a health facility at any time and that a continual risk of the nosocomial transmission of measles exists. The present review makes two groups of recommendations: those which are generally applicable to all countries, and certain additional recommendations which may be suitable only for industrialized countries.

Overview of poliomyelitis in the African Region and current regional plan of action.

The African Region of the World Health Organization includes a diverse membership of 48 countries and territories that has made substantial progress toward controlling poliomyelitis. The coverage with three doses of oral poliovirus vaccine among 1-year-old children reached 58% in 1995, a substantial increase from 49% in 1993, and the incidence of poliomyelitis decreased from 5126 cases in 1980 to 1597 in 1995. To interrupt poliovirus circulation, 29 countries planned to conduct either national immunization days (25 countries) or subnational immunization days (4 countries) during 1996. To ensure the success of these efforts, high-level political commitment has been obtained in many countries, and the campaign to "Kick polio out of Africa" is supported by some of the most respected African politicians. Provided the necessary resources can be obtained from internal and external sources, the African Region may be able to achieve the eradication of poliomyelitis by the year 2000 or shortly thereafter.

Current status of polio eradication in Southern Africa.

During the 1990s, poliomyelitis transmission in 11 mainland and island nations of southern Africa appeared relatively low. However, the implementation of specific strategies recommended by the World Health Organization for eradicating polio in southern Africa began only in 1994. In 1995, oral poliovirus vaccine coverage (three doses) among infants was > or = 75% in all but 4 countries. National immunization days (NIDs) to control polio outbreaks were carried out in Namibia in 1994 and 1995. Angola, Botswana, and South Africa carried out subnational NIDs in 1995. All countries in southern Africa except Madagascar planned NIDs in 1996. Epidemiologic surveillance of acute flaccid paralysis (AFP) and laboratory surveillance of wild poliovirus was launched after nationwide training workshops in 7 mainland countries and is planned in the remaining countries by the end of 1996. Analysis of recommended performance indicators of AFP surveillance shows that substantial progress was made during 1994-1995, and the prospects for the certification of polio-free status in southern Africa on target appear good.

Poliomyelitis in Angola: current status and implications for poliovirus eradication in Southern Africa.

As part of emergency assistance to the Ministry of Health (MOH), national surveillance data for poliomyelitis and charts of cases at the national rehabilitation hospital were reviewed. Poliomyelitis patients admitted to Angola's main pediatric hospital were examined. A mean of 86 cases of poliomyelitis/year were reported in Angola during 1989-1994. Review of records from non-MOH sources uncovered another 74 cases, primarily from areas outside governmental control. Hospital chart reviews revealed that 80% of the cases were children <3 years of age, mainly unvaccinated. Molecular analyses of isolates from cases in Luanda and at the Angola-Namibia border suggest that these isolates are closely related and that > or = 2 strains of wild poliovirus type 1 are circulating currently in Angola. This investigation confirms that poliomyelitis has remained endemic in Angola since independence in 1975. It affects primarily young and unvaccinated children. Control of poliomyelitis in Angola is essential to expand the polio-free zone in southern Africa.

Polio outbreaks in Namibia, 1993-1995: lessons learned.

In 1993, a nationwide outbreak of 53 cases of paralytic poliomyelitis occurred in Namibia. The World Health Organization-recommended supplemental vaccination strategy of national immunization days (NIDs), providing two doses of oral polio vaccine (OPV) to all children <5 years, was implemented to control the epidemic. A second focal outbreak of 16 confirmed polio cases occurred during 1994-1995 in northeast Namibia. "Mopping-up" vaccination was implemented to control the second outbreak, followed by NIDs. Both epidemics appeared to be associated with wild poliovirus importation from Angola, where polio is endemic. Although supplemental vaccination measures achieved suboptimal OPV coverage, surveillance of acute flaccid paralysis has not detected wild poliovirus in Namibia since April 1995. Future NIDs should aim to ensure OPV coverage >90% in each round of NIDs in each district. Nevertheless, the risk of new poliovirus importations will continue until efforts in Angola to increase routine coverage with three doses of OPV and extend supplemental vaccination activities can be implemented.

Strategies for minimizing nosocomial measles transmission.

As a result of the highly contagious nature of measles before the onset of rash, nosocomial transmission will remain a threat until the disease is eradicated. However, a number of strategies can minimize its nosocomial spread. It is therefore vital to maximize awareness among health care staff that an individual with measles can enter a health facility at any time and that a continual risk of the nosocomial transmission of measles exists. The present review makes two groups of recommendations: those which are generally applicable to all countries, and certain additional recommendations which may be suitable only for industrialized countries.

Measles vaccine efficacy in Masvingo district, Zimbabwe.

OBJECTIVE: To carry out a survey in Masvingo District to determine the efficacy of measles vaccine. DESIGN: A retrospective study, using existing health care facility records and interviews with care givers. SETTING: Using the standard WHO-EPI cluster sampling methodology, 30 clusters were randomly selected in Masvingo District. SUBJECTS: 14 or more children in each of the 30 clusters were selected. MAIN OUTCOME MEASURES: Occurrence of measles or lack of it among the children aged 12 to 23 months, age at vaccination, status, the age at which the child had measles and availability of a health card. RESULTS: In Masvingo District from 1987 to 1994, measles incidence remained very high, though mortality drastically declined. Using field survey data measles vaccine efficacy was estimated at 78.3pc (95pc CI 54.1; 89.8). Vaccine coverage was estimated to be 75pc. CONCLUSION: The efficacy results fall at the lower end, but within the normal limits, of those expected for measles vaccine as used in Zimbabwe. Steps to increase vaccine coverage are of the highest priority.

Epidemiology of poliomyelitis in the United States one decade after the last reported case of indigenous wild virus-associated disease.

Poliomyelitis caused by wild poliovirus has been virtually nonexistent in the United States since 1980, and vaccine-associated paralytic poliomyelitis (VAPP) has emerged as the predominant form of the disease. We reviewed national surveillance data on poliomyelitis for 1960-1989 to assess the changing risks of wild-virus, vaccine-associated, and imported paralytic disease; we also sought to characterize the epidemiology of poliomyelitis for the period 1980-1989. The risk of VAPP has remained exceedingly low but stable since the mid-1960s, with approximately 1 case occurring per 2.5 million doses of oral poliovirus vaccine (OPV) distributed during 1980-1989. Since 1980 no indigenous cases of wild-virus disease, 80 cases of VAPP, and five cases of imported disease have been reported in the United States. Three distinct groups are at risk of vaccine-associated disease: recipients of OPV (usually infants receiving their first dose), persons in contact with OPV recipients (mostly unvaccinated or inadequately vaccinated adults), and immunologically abnormal individuals. Overall, 93% of cases in OPV recipients and 76% of vaccine-associated cases have been related to administration of the first or second dose of OPV. Our findings suggest that adoption of a sequential vaccination schedule (inactivated poliovirus vaccine followed by OPV) would be effective in decreasing the risk of VAPP while retaining the proven public health benefits of OPV.

Poliomyelitis case confirmation: characteristics for use by national eradication programmes.

Highly sensitive case definitions were first introduced by national poliomyelitis eradication programmes to avoid missing true cases of the disease, though false-positive diagnostic errors could still occur owing to low specificity. Extensive data from all 1620 cases of acute, flaccid paralysis reported in Brazil during 1987-88 provided an opportunity to study the characteristics of confirmed poliomyelitis cases and epidemiologically to evaluate potential case definitions that maximized both sensitivity and specificity. Cases that had been confirmed by wild poliomyelitis virus isolation were compared with those that had been rejected (non-polio cases). To guarantee the consistency of clinical, epidemiological and laboratory investigations, only cases less than 10 years of age that had been investigated within 15 days of the onset and with complete laboratory specimens were included. No single practical case definition combining both high sensitivity and high specificity emerged from the study. However, the results showed that poliomyelitis endemic countries with limited resources should give priority to the investigation of cases in less than 5-year-olds, cases with prodromal fever, cases without involvement in all four limbs, cases without progression greater than 3 days after the onset, and cases occurring in areas where poliomyelitis had recently been confirmed. In countries without laboratory resources, cases of acute, flaccid paralysis with initial involvement in one or both lower limbs and residual neurological sequelae at 60 days should be confirmed. Countries that are close to eradication may selectively reject any cases lacking laboratory confirmation, despite adequate specimen collection, if they do not have initial involvement in one or both lower limbs and residual neurological sequelae at 60 days.

PIP: In Sao Paulo, Brazil, physicians followed 85 full term, healthy, breast fed infants born between March 1986-September 1988 monthly for 1 year to compare their immunologic response to immunization with trivalent oral poliovirus vaccine (TOPV). They either received doses 1 day after birth and at 2, 4, and 9 months (group A) or at 2, 4, and 6 months (group B). They analyzed blood samples from the mother at childbirth, from the umbilical cord, and from the infant at 2, 4, 6, 9, and 12 months to measure poliovirus neutralizing antibodies. All but 1 infant had passively transferred antibodies at birth. Group A had higher polio antibodies during the 1st few months, greater seropositivity, and a lower proportion of susceptible infants than group B. In fact, at the end of 12 months, only 3.7% of infants in group A were susceptible to all 3 poliovirus types compared to 25.9% in group B. Seroconversion rates were considerably higher in group A infants from the 3rd dose forward (96.3-100%) than for those in group B (74.1-100%). The response for polioviruses 1 and 2 were essentially the same in both groups at 12 months (96.3-100%). The immunological response to poliovirus type 3 in group A was superior to that of group B at the end of 1 year (96.3% vs. 74.1%), however. Yet group B infants received their 1st dose of the vaccine at 2 months with a higher level of poliovirus 3 type (500,000 TCID50/dose) than group A infants received at birth (300,000 TCID50/dose). Thus immunization of newborns with TOPV provided more protection against polio than a higher vaccine concentration administered to infants beginning at months. This finding is especially relevant since polio type 3 was responsible for the polio outbreak in 1986 in northern Brazil.