Thailand Expanded Program on Immunization: a ten-years review of coverage and impact on EPI target diseases.

The national immunization coverage in Thailand for all types of vaccine has been steadily increasing since 1978, when the EPI was formally launched. The coverage in 1987 was 96% for BCG, 75% for DPT, 74% for OPV, and 60% for TT. Measles vaccine, which started only in late 1984, had the lowest coverage, 51%, in 1987. During the period 1982-1987, the drop-out rates between the first and third dose of DPT and OPV decreased dramatically from 69% to 13% and from 42% to 13% respectively. Sampling surveys of immunization coverage showed higher coverage for DPT and OPV than those from reporting in all regions, especially in the capital city which has a high concentration of the private health sector. Only the northeastern region had less coverage from surveys than from reporting. Following the launch of EPI, the disease incidence demonstrated a clearly downward trend for diphtheria, poliomyelitis, and measles, while in the case of pertussis and neonatal tetanus, slower of still fluctuating declines were observed. The reported age-specific incidences per 100,000 population in 1986 for children 0-4 years were as follows: 4 for diphtheria, 0.9 for poliomyelities, 180 for measles, 14 for pertussis, and 10 for tetanus.

Oral rehydration therapy in a rural area, northern Thailand.

A cross-sectional sampling survey of mothers' practice of ORT in Amphoe Bunpotphesai in the northern part of Thailand included 1,619 children under five. Two hundred and six children were reported to have 223 diarrheal episodes. The incidence of diarrhea in children under five was 3.4 episodes per child per year. When children had diarrhea 65.5 per cent of mothers sought help from health providers, 25.2 per cent treated their children with drugs bought from stores, 2.3 per cent used herbal medicine and 6.1 per cent did not treat their children. 50.7 per cent of diarrheal episodes mother gave ORT, using ORS 19.7, commercial electrolytes mixture 16.6 and home available fluid 14.4 per cent. The accuracy of dilution of electrolytes powder from the packets was checked in 80 incidences. 31.8 and 27.8 per cent of mothers made correct dilution of ORS and commercial electrolytes products respectively. Health providers carried both ORS and commercial electrolytes packets. ORS added to a glass of water was found in 13.6 per cent which was 3 times concentrated. Commercial electrolytes products were too dilute in 72.2 per cent. 17.5 per cent of mothers divided electrolytes powder to add in one spoon of water to treat their children as one drug dose. Data showed that the ORT use rate was 50.7 per cent. Home available fluid was used by 14.4 per cent. ORT should be further promoted to control diarrheal diseases and health providers should give instructions to every mother or child minder on how to dispense ORS or electrolytes packets for appropriate dilution and use.

PIP: From June 8-17, 1987, researchers observed oral rehydration therapy (ORT) practices of 200 mothers of children 5 years old and ill with diarrhea in a rural area of northern Thailand. 206 of 1619 children (12.7%) had at least 1 episode of diarrhea during the study period (223 diarrheal episodes). Researchers estimated the number of episodes of diarrhea/year/child to be 3.4 46.1% of the cases experienced mild diarrhea and no child had severe diarrhea. 70.9% of children 2 years old experienced diarrhea during the study period. These children had the highest proportion of diarrheal incidence. 25.2% of the mothers treated the diarrhea with drugs, while 67.8% went to health providers for treatment. 47.5% of the mothers did not treat their children's diarrhea with ORT. 19.7% of those that did treat their children with ORT used WHO's ORS packets, 16.6% used commercial electrolyte mixtures, and 14.4% used home available fluid. Researchers checked the accuracy dilution of ORS and commercial electrolyte packets in 80 cases of diarrhea. Only 31.8% of ORS was correctly prepared. Further, 13.6% of ORS preparations were 3 times too concentrated--a potentially harmful concentration. Only 27.8% of the commercial packets was correctly diluted. The rest were too diluted. Researchers theorized that these mothers either did not read the instructions on the packets and/or did not receive any instructions from the health providers on how to correctly prepare ORT. No child had any adverse effects as a result of improper preparation, however.

The Thai expanded programme on immunization: role of immunization sessions and their cost-effectiveness.

A cost-effectiveness study of the Thai expanded programme on immunization was carried out in district hospitals and health centres in Thailand during early 1987. The total annual spending on immunization was US $3852 in hospitals and US $813 in health centres. The percentage distribution of annual costs was similar in both facilities. Salaries were the largest component, followed by building and vaccine costs. The frequency of immunization sessions was the most important factor in determining total costs--immunization costs increasing with the frequency of sessions. In hospitals the average number of fully immunized children was 184, compared with 49 in health centres. The cost per fully immunized child varied widely from US $5.30 to US $33.20, and the most cost-effective facilities were those that immunized the greatest number of children. With the present number of health facilities in all areas of the country, which correspond to saturation levels, the most likely way for the Thai programme to reduce costs would be to make better use of staff time by decreasing the frequency of the services offered, thereby increasing the efficiency of each session. Hospitals should adjust the frequency of their immunization sessions according to the number of children being served, but health centres should offer sessions only monthly or once every two months.

PIP: A cost-effectiveness study of the extended immunization program in Thailand surveyed data from 4 provinces for the fiscal year of 1986. The study's objective was to better use scarce health resources especially in difficult economic times. The survey assessed the total annual spending for hospitals and health centers in U.S. dollars: $3,582 in hospitals and $813 in health centers. In relation to the number of 1 year old children in their respective area, hospitals showed 100% coverage of immunization and not more than that. The vaccine was administered in predetermined clinics that also continued with supplementary outreach activities. The immunization costs for each child was $13.80 in hospitals and $11.80 in health centers and $8.90 and $10.30, respectively for pregnant women. Higher administrative and construction expenses caused hospitals to have higher immunization costs than health centers. Salary was identified as the major factor in both operating and total costs. The output and coverage in hospitals was better than that of centers. Higher hospital costs could be justified by the frequency of immunization and the service load. The hospital immunization sessions should be organized according to service load with the frequency increasing with the number of children. Potential factors such as a decrease in birth rate and the change-over of users to local care should be considered in future studies of immunization coverage and effective health facility use.