Improving the monitoring of immunization services in Kyrgyzstan.

Following the disbanding of the Soviet Union in 1991, the government of Kyrgyzstan was unable to maintain the previous level of health services. To revitalize the health services, the Ministry of Health (MOH) first focused on improving their immunization services, including the immunization component of the Health Management Information System (HMIS). Secondly, to increase immunization coverage, the MOH set as a priority the elimination of prescribing false contraindications to immunization. To accomplish both goals, the MOH updated the national immunization policies and established a more effective structure for managing immunization services. To support the MOH, the US Agency for International Development (USAID) Resources for Child Health (REACH) and Basic Support for Institutionalizing Child Survival (BASICS) projects provided technical assistance through a resident coordinator and consultants, and by organizing an international seminar. The improvements extended beyond systems and forms, but, instead, emphasized monitoring by the frontline health worker and supervising the quality of health information. To accomplish their objectives, the MOH appointed a Working Group to define the problems, revise record-keeping procedures, and develop monitoring tools. This group, representing both national and local levels, was composed of MOH epidemiologists, paediatricians and a management information specialist. To reduce the burden of excessive record-keeping and reporting requirements, the Working Group identified four key indicators for the service delivery level: (1) DPT3 immunization coverage rates for children less than 1 year of age; (2) contraindication rates for DPT; (3) usage of DPT vaccine; and (4) daily refrigerator temperatures. Additional indicators were included at district and provincial levels. After a successful 1-year trial, the MOH implemented the revised HMIS nationally. Not only did the quality of the information system improve, but the new approach provided visible evidence, from facility to national levels, that the MOH was approaching their objective of reducing contraindication rates for DPT immunizations to 5% or less, and that vaccine wastage could be substantially reduced. The project demonstrated that giving health workers the basic epidemiologic skills to monitor their own work measurably improved the quality of the data, and by acquiring the new skills, the workers developed a sense of pride in their work.

PIP: Following the disbanding of the Soviet Union in 1991, the government of Kyrgyzstan was unable to maintain the previous level of health services. To revitalize the health services, the Ministry of Health (MOH) first focused on improving their immunization services, including the immunization component of the Health Management Information System (HMIS). Secondly, to increase immunization coverage, the MOH set as a priority the elimination of prescribing false contraindications to immunization. To accomplish their objectives, the MOH appointed a Working Group to define the problems, revise record-keeping procedures, and develop monitoring tools. To reduce the burden of excessive record-keeping and reporting requirements, the working group identified four key indicators for the services delivery level: 1) diphtheria, pertussis, tetanus (DPT) immunization coverage rates for children less than 1 year of age; 2) contraindication rates for DPT; 3) usage of DPT vaccine; and 4) daily refrigerator temperature. After a successful 1-year trial, the MOH implemented the revised HMIS nationally. Not only did the quality of the information system improve, but also the new approach provided visible evidence that the MOH was approaching its objectives. The project demonstrated that giving health workers the basic epidemiological skills to monitor their own work measurably improved the quality of the data, and by acquiring the new skills, the workers developed a sense of pride in their work.

A low-cost, community-based measles outbreak investigation with follow-up action.

An outbreak of measles in Kampala, Uganda, in 1990 raised concern about the effectiveness of the measles vaccine that was used. The Uganda EPI programme and the medical office of the Kampala City Council therefore conducted a community-based investigation, with door-to-door interviews in two selected communities. They revealed 68 measles cases ranging in age from 5 months to 12 years; the highest age-specific attack rate (32%) was found in children aged 12 to 23 months. BCG immunization coverage was high (85%), but measles immunization coverage was moderate (48%). One community, served by a mobile clinic, presented a vaccine efficacy of only 55%. Responses by mothers revealed that many had failed to have their children completely immunized because of a lack of information, and not because of difficulties in access to the service. In a follow-up, community leaders initiated monthly checking of immunization cards of both children and mothers. The low vaccine efficacy found in one of the communities resulted in a thorough assessment of the city's cold chain. This community-based approach proved to be cost-effective and practical for identifying the obstacles to effective immunization delivery.

PIP: An outbreak of measles in Kampala, Uganda in 1990 raised concern about the effectiveness of the measles vaccine that was used. The uganda Expanded Program on Immunization and the medical office of the Kampala City Council therefore conducted a community-based investigation, with door-to-door interviews in 2 selected communities. They revealed 68 measles cases ranging in age from 5 months to 12 years; the highest age- specific attack rate (32%) was found in children aged 12-23 months. BCG immunization coverage was high (85%), but measles immunization coverage was moderate (48%). 1 community, served by a mobile clinic, presented a vaccine efficacy of only 55%. Responses by mothers revealed that many had failed to have their children completely immunized because of the lack of information, and not because of difficulties in access to the service. In a followup, community leaders initiated monthly checking of immunization cards of both children and mothers. The low vaccine efficacy found in 1 of the communities resulted in a thorough assessment of the city's cold chain. This community-based approach proved to be cost-effective and practical for identifying the obstacles to effective immunization delivery. (author's)

A perspective on controlling vaccine-preventable diseases among children in Liberia.

PIP: In 1978 the Ministry of Health and Social Welfare (MHSW) of Liberia launched the Expanded Program on Immunization (EPI) with the 5-year objective of establishing an 80% reduction in child mortality and morbidity from measles, polio, diphtheria, neonatal tetanus, pertussis, and tuberculosis. The program at first adopted a strategy of using 15 mobile units in 11 operational zones to deliver vaccinations throughout the country. However, by 1980, despite support from the Baptist World Alliance, the UN International Children's Emergency Fund (UNICEF), and the World Health Organization (WHO), it became evident that the mobile strategy was neither economically feasible nor practical. Therefore, with support from the US Agency for International Development (USAID), the EPI shifted to a strategy of integrating immunization activities into the existing network of state health facilities. After 5 years, in 1982, the Program was evaluated by a team from the MHSW, WHO, USAID, and the Centers for Disease Control. The evaluating team felt that the EPI's strategy was good, but its goals were not being achieved due to deficiencies in funding, clinic supervision, and rural community outreach, as well as shortages of kerosene and spare parts needs to keep the essential refrigerators in operating condition. Measles remains endemic; in the capital, Monrovia, only 9% of the children have been vaccinated against it. Immunization coverage is particularly low in the capital the countries. Other reasons for low vaccination coverage in Liberia are lack of community awareness of existing facilities and the importance of vaccination and lack of coordination at the community level to use the existing facilities efficiently. International assistance is still needed, especially to develop heat-stable vaccines, so that maintenance of refrigerators will not be necessary.^ieng

Pre-exposure immunization against rabies: a re-emphasis for veterinarians.

A serologic service for determining antibody levels due to prior rabies immunization was provided at an annual convention of the Tennessee Veterinary Medical Association in January 1977. A total of 26 veterinarians volunteered to participate, and only 2 had adequate serum levels of antibody related solely to a pre-exposure immunization. An additional six veterinarians had high titers of antibody-probably the result of post-exposure immunization after rabies-proved incidents. The level of protection for veterinarians appears to be low, which suggests a need for a re-emphasis on immunizations and for increased availability of the relatively new human diploid cell vaccine.

A statewide characterization of hospital infection control practices and practitioners.

Selected features of infection control programs among the 163 general hospitals in Tennessee were surveyed in 1976 and 1979. Each hospital but one had a designated infection control practitioner. Three-fourths of the hospitals had fewer than 200 beds and most were in rural areas. The practitioners in these small hospitals worked in an isolated professional milieu: few (4%) had attended a basic training course or were members of a national (11%) or local (16%) infection control association. They also had significantly less access to standard infection control resource publications than did practitioners in large hospitals. Use of aqueous quaternary ammonium compounds for disinfection was reported by 37% of all hospitals in 1979; 68% of hospitals routinely performed bacteriologic cultures of personnel or the environment. In contrast, only 3% of hospitals did not have a policy specifying the use of sterile closed-system drainage of indwelling bladder catheters. Although these practices varied somewhat by hospital size, the differences were not statistically significant. Modest improvement in each parameter was noted since 1976. Pathology was the most common medical specialty (34%) among chairman of infection control committees; internal medicine and pediatrics accounted for only 13%. The practice of routine microbiologic monitoring was significantly more common among hospitals with chairmen who were pathologists. The implications of these findings for national priorities in hospital infection control are discussed.

An outbreak of Legionnaires' disease associated with a contaminated air-conditioning cooling tower.

In August and September 1978, an outbreak of Legionnaires' disease occurred in Memphis, Tennessee. Of the 44 ill, 39 had been either patients, employees, visitors, or passers-by at one Memphis hospital (Hospital A) during the 10 days before. Assuming an incubation period of between two and 10 days, the onset of cases correlated precisely with the use of Hospital A's auxiliary air-conditioning cooling tower. L. pneumophila was recovered from two samples of water from the tower. Infection appeared to have occurred both outside and within the hospital. A significant association was demonstrated between acquisition of Legionnaires' disease and prior hospitalization in those areas of Hospital A that received ventilating air from air intakes near the auxiliary cooling tower. Tracer-smoke studies indicated that contaminated aerosols from the tower could easily reach these air intakes, as well as the street below, where four passers-by had been before they contracted Legionnaires' disease. This represents a common-source outbreak in which the source of L. pneumophila infection and airborne transmission were identified.

Legionnaires' disease in Kingport, Tennessee.

In August and September 1977 a discrete cluster of 27 serologically or pathologically confirmed cases of Legionnaires' disease, plus six highly presumptive cases were identified in the area of Kingsport, Tennessee. Three patients died. Most patients manifested severe pneumonia and fever; no mild or asymptomatic disease forms were recognized despite intensive case-finding efforts. Illness was epidemiologically associated with residing, visiting, or working in one geographic area of Kingsport, residence there being the factor most strongly associated. Although the attack rate for area residents was 0.64%, the randomly determined prevalence of serologic reactors was 5.2%, which is not significantly different from that in a nonimplicated control neighborhood. The epidemic did not correlate temporally with any identified environmental or demographic event. No source of the bacterium was found either by a detailed case-control study of area associations or by bacterial isolation from sentinel guinea pigs or environmental specimens. There was no evidence of person-to-person spread.