Measles and Rubella Global Strategic Plan 2012-2020 midterm review.

KEY HIGHLIGHTS: 1. Measles eradication is the ultimate goal but it is premature to set a date for its accomplishment. Existing regional elimination goals should be vigorously pursued to enable setting a global target by 2020. 2. The basic strategic approaches articulated in the Global Measles and Rubella Strategic Plan 2012-2020 are valid to achieve the goals but have not been fully implemented (or not appropriately adapted to local situations). 3. The report recommends a shift from primary reliance on supplementary immunization activities (SIAs) to assure two doses of measles-containing vaccine (MCV) are delivered to the target population to primary reliance on ongoing services to assure administration of two doses of MCV. Regular high quality SIAs will still be necessary while ongoing services are being strengthened. 4. The report recommends a shift from primary reliance on coverage to measure progress to incorporating disease incidence as a major indicator. 5. The report recommends that the measles/rubella vaccination program be considered an indicator for the quality of the overall immunization program and that measles/rubella incidence and measles and rubella vaccination coverage be considered as primary indicators of immunization program performance. 6. Polio transition presents both risks and opportunities: risks should be minimized and opportunities maximized. 7. A school entry immunization check could contribute significantly to strengthening overall immunization services with assurance that recommended doses of measles and rubella vaccines as well as other vaccines have been delivered and providing those vaccines at that time if the child is un- or under-vaccinated. 8. Program decisions should increasingly be based on good quality data and appropriate analysis. 9. The incorporation of rubella vaccination into the immunization program needs to be accelerated - it should be accorded equivalent emphasis as measles. 10. Outbreak investigation and response are critical but the most important thing is to prevent outbreaks.

Eradication of poliomyelitis: progress in the Americas.

In the span of 5 years since the eradication initiative was launched and only 3 years since external funds were made available, PAHO has been able to develop and implement a comprehensive program strategy for polio eradication that includes the following components: achievement and maintenance of high immunization levels (which include the supplemental strategies of national immunization days and mop-up operations); effective surveillance to detect all new cases; and a rapid response to the occurrence of new cases. Despite yearly increases in the number of cases of acute flaccid paralysis reported to the surveillance system, a decline in reported confirmed cases of polio has occurred since 1986 to record low levels in 1989. Cases in 1989 were reported from only 0.7% of the counties in the Americas. The occurrence of 24 wild-type virus isolates in 1989 were limited to only three geographic areas: northwestern Mexico; the northern Andean Region; and northeastern Brazil. At this writing the clock is ticking with only 3 months left to achieve the goal of interrupting transmission by the end of 1990. If the current level of effort is sustained and special efforts are directed at the remaining foci of infection, the eradication of the transmission of wild-type poliovirus from the Americas can be achieved. Continued external financial support will be critical if the effort is to succeed. The prospect of poliomyelitis eradication in the Americas led the 41st World Health Assembly of WHO to adopt a resolution in May, 1988, to eradicate the indigenous transmission of wild-type poliovirus from the world by the year 2000.(ABSTRACT TRUNCATED AT 250 WORDS)

The impact of immunization control activities on measles outbreaks in middle and low income countries.

BACKGROUND: The World Health Organization recommended strategy for responding to measles outbreaks in developing countries does not promote the use of immunization campaigns due to their high cost, disruptive nature and limited impact. Given the substantial morbidity and mortality associated with such outbreaks, a literature review was conducted as a basis for re-evaluating this policy. METHODS: Reports of supplementary immunization activities that were performed to control measles outbreaks in middle or low income countries were identified. The impact of the immunization activities on the course of each outbreak was evaluated by examining the data provided. RESULTS: Of 66 reports detailing a measles outbreak in a middle or low income country, 17 described supplementary immunization activities which included seven 'non-selective' immunization campaigns, three 'selective' campaigns and one use of an early 2-dose schedule. Eight of the reports commented on the impact of the response, five of which reported a reduction in outbreak morbidity. Only one of the reports, from an isolated island outbreak, provided sufficient data to support a possible reduction in outbreak-associated morbidity. CONCLUSIONS: There are limited data on the impact of measles outbreak immunization activities from developing countries. The available data do not support a change in the WHO recommended strategy for conducting a limited, if any, immunization response to such outbreaks. Immunization strategies which aim to prevent outbreaks may be more effective than campaigns to interrupt transmission of an outbreak which has already begun.

PIP: Because of their high cost, disruptive nature, and limited impact, immunization campaigns are not recommended by the World Health Organization (WHO) in response to measles outbreaks in developing countries. The authors reviewed the available literature to assess whether that WHO policy should stand or be changed. 66 reports were identified detailing a measles outbreak in middle- or low-income countries. 17 of those reports described supplementary immunization activities to control measles outbreaks which included seven nonselective immunization campaigns, three selective campaigns, and one use of an early two-dose schedule. Eight reports commented upon the impact of the intervention, five of which reported a reduction in outbreak morbidity. Only one report, from an isolated island outbreak, provided sufficient data to support a possible reduction in outbreak-associated morbidity. The available data therefore do not support a change in the WHO-recommended strategy. Immunization strategies to prevent outbreaks may be more effective than campaigns to interrupt transmission of an outbreak which has already begun.

Wernicke's syndrome after bariatric surgery.

Two young females with severe morbid obesity presented with Wernicke's syndrome after Roux-en-Y gastro-jejunum bypass had been performed. The first patient had recurrent vomiting and dyplopia two months post-surgery. Physical examination indicated bilateral ophthalmoparesia with conserved convergence and ataxia. The second patient had frequent vomiting episodes over the previous three months together with lower limb hypotonia, myoclonia and generalised tonicoclonic seizures on two occasions within one year of surgery. In both cases routine blood test, ion levels (sodium, potassium, calcium, phosphates), electroencephalogram and CT scan were normal. Thiamine therapy was instigated on the basis of clinical intuition and the first patient achieved complete remission within 24 hours while the second improved gradually in that two years later only mild lower limb hypotonia and a slight cognitive deficit remains. Erythrocyte transketolase activity determinations were abnormal on two separate occasions for this second patient. Vitamin B1 determinations were not available for the first patient. In conclusion, the restriction in energy intake and the persistent vomiting together with malabsorption induced by the surgical intervention could explain the vitamin deficiency causing Wernicke's encephalopathy. This indicates a need for close monitoring and systematic vitamin supplementation in those patients who undergo bariatric surgery.

[Mini Mental State Examination: association of the score obtained with the age and degree of literacy in an aged population]. / Mini Mental State Examination: asociación de la puntuación obtenida con la edad y grado de alfabetización en una población anciana.

BACKGROUND: To differentiate dementia from the normal human decline scales may be used in an attempt to identity and quantify the cognitive damage which a subject may present. The Mini Mental State Examination (MMSE) is one of those. This study was performed to identify the relation of the responses between the MMSE and the sociodemographic variables of the subjects. METHODS: The MMSE was applied as a tool to determine the presence of cognitive alterations in a prospective study of people over the age of 65 years from La Selva del Camp (Baix Camp, Catalonia, Spain). The population was differentiated according to the cut off point (24 points) with the relation of the score obtained by each subjects being studied with the sociodemographic variables of the same. RESULTS: The mean score obtained in the test by the total population was: (mean +/- SD) 23.9 +/- 4.5 points; 24.6 +/- 4.9 in the males and 22.5 +/- 5.8 in the females. In the age group 65-74 years the mean score was 24.8 +/- 3.8; 23 +/- 4.6 in those from 75-80 years and 21.4 +/- 6 in the age group over 85 years. Sex was significantly associated (p = 0.0003), as were age (p = 0.0002) and the degree of alphabetization (p = 0.0000) with women obtaining a lower MMSE score than men, the most elderly was lower than that obtained by the younger and those of less alphabetization lower than those with education. CONCLUSIONS: Although the MMSE is a good tool for the detection of cognitive alterations in a population, it must be kept in mind that the result of this test may be influenced by the age and education of the subject and should therefore not be used as an exclusive element in the diagnosis of dementia.

Progress towards the eradication of poliomyelitis globally and in Africa, January 2000.

Led by an international partnership including Rotary International, the WHO, UNICEF and the Centers for Disease Control and Prevention in the USA, the global initiative to eradicate poliomyelitis has made remarkable progress since its beginning in 1988. The number of polio cases has decreased from an estimated 350,000 cases in 1988 to just over 5,000 reported cases in 1999. Following successful eradication from the WHO Region of the America's, certified as polio-free in 1994, wild poliovirus was last reported from the Western Pacific Region (including China) in 1997, and from the European Region (including all countries of the former Soviet Union) in November 1998. Large parts of Southern and Northern Africa and the Middle East are also polio-free. This success is related to the implementation of annual nationwide supplemental oral poliovaccine (OPV) campaigns in all recently or currently polio-endemic countries, targeting all children under 5 years with two doses of OPV. Progress of the initiative is monitored by special surveillance systems for all cases of acute flaccid paralysis (AFP) in children under 15 years, including virological testing to rule out wild poliovirus infection. The initiative currently focuses on a limited number of remaining endemic countries in South Asia and Africa, including India, Pakistan, Bangladesh, and Nigeria. The initiative is also beginning to be successful in several countries affected by conflict situations, such as Afghanistan, Sudan (South), Somalia, Democratic Republic of the Congo and Angola.

[Eradication of poliomyelitis from the American continent]. / Eradication de la poliomyélite du continent américain.

A strategy to eradicate poliomyelitis from America was developed in 1985 by the PAHO. The last case of poliomyelitis due to wild virus was detected in August 1991 in the Andean region of Peru. The main strategies used to eradicate polio are: 1) attainment of high immunization levels, 2) biannual National Vaccination Campaigns with OPV in all poliomyelitis infected countries, 3) organization in all America countries of effective surveillance of AFP, 4) setting up of a laboratory network for the isolation of the wild poliovirus from cases and contacts' stools samples and 5) the organization of a rapid response, to the occurrence of any new case with door to door vaccination (Mop-up). These strategies have been recommended by the WHO for Global Eradication of Poliomyelitis by the Year 2000. The next step in the Americas is to confirm the eradication of poliomyelitis. An ICPEC has been organized and the condition required to certify the eradication is the absence of cases of virologically confirmed indigenous poliomyelitis by a period of at least three years in the context of continued adequate surveillance. Four elements will be taken into consideration when confirming the eradication of poliomyelitis: 1) the surveillance of AFP, 2) the surveillance of wild poliovirus, 3) active searches for AFP cases in areas of risk, such as those areas with poor surveillance, or where there have been compatible cases, 4) documentation of mop-up operations in areas of risk.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tobacco brand-related headache]. / Cefaleas relacionadas con marcas de tabaco.

INTRODUCTION: Tobacco smoking has been considered a risk factor for headache by some authors, while others disagree because of contradictory data. PATIENTS AND RESULTS: We describe the clinical aspects of eleven patients (four men and seven women) who presented to us with tobacco brand-related headaches. Clinical history help us to discover that headache of each patient was directly related with certain cigarette brands smoking. The cigarette brands implicated were diverse and different for each patient. Headaches were migraine-like in seven cases, cluster-like in three, and non-specific in the other one. They disappeared after switching brand or stopping smoking. CONCLUSIONS: In our patients, headaches were clearly related to smoking certain brands of cigarettes, which has never been reported before. This type of headache has characteristics that suggest that it could be a particular form of chemical odour intolerance, previously described. The number of possible responsible substances is large. More studies will be necessary in order to discover the mechanism leading patients to tobacco brand-related headache. It is important to ask our patients which cigarette brand they smoke, so it is possible to solve the problem.

Disease eradication as a public health strategy: is measles next?

Following the failure of disease eradication efforts in the first half of this century, the success of smallpox eradication and the ongoing initiatives against poliomyelitis and dracunculiasis are re-establishing eradication as a viable disease control strategy. The perpetual benefits of eradication, together with the positive impact that such initiatives can have on health services in general, are changing the world's perception of these endeavours. Among the most obvious examples of this changing trend is the recent enthusiasm in both industrialized and developing countries for re-exploring the eradicability of measles. Increasingly, it appears that measles, the single leading cause of vaccine-preventable childhood morbidity and mortality worldwide, may be the next major organism targeted for global eradication.

Prevalence of dementia in a semi-rural population of Catalunya, Spain.

This study was to investigate the prevalence of dementia in an aging population. A two-phase model was used to obtain information on the socio-demographic, medical and cognitive status of subjects over 65 years of age (n = 516), resident on December 31, 1990, within the general population (n = 3,457) of La Selva del Camp. A diagnostic protocol, following the criteria of DSM-III, was designed for application to all subjects. We diagnosed 64 subjects with dementia, which represented a prevalence of 14.9% of which 3.2% was classified as severe, 4.5% as moderate and 7.3% as slight. The prevalence by age and sex showed a large increase with age and a higher prevalence in females, although the latter was not statistically significant.

The desired field-performance characteristics of new improved vaccines for the developing world.

Although the vaccination initiatives undertaken during the past decade are the cornerstones for protecting the world's children and helping to ensure their survival and development, the vaccines currently being employed may become obstacles for further disease reduction or eradication. Their characteristics complicate or increase the burden on health care infrastructures to maintain or expand vaccine delivery systems. This paper examines an experience with the vaccine technologies that currently are being used by immunization programs in developing countries, illustrating the field problems and obstacles associated with their use. It discusses the advantages and benefits that would accrue if new or improved, heat-stable, multi-antigen vaccines that require only one or two, preferably oral, doses were to become available.

PIP: Smallpox was eradicated in 1977 with immunity conferred by a simple, heat-stable vaccine administered in single doses. Most currently available vaccines used against vaccine-preventable diseases, however, require refrigeration and administration in multiple doses. The recurrent costs of managing and administering such vaccines are high. A new set of vaccines is therefore called for. Ideal vaccines will be administered in one or two doses, be taken earlier in life, have no side effects, be heat-stable and not require refrigeration in the field. The availability of such vaccines would ensure the control and/or eradication of diseases, reduce costs on health systems and parents, and encourage parents to vaccinate their children. This paper reviews vaccine technologies currently used in immunization programs in developing countries discusses associated field problems and obstacles. Advantages and benefits of new or improved multi-antigen vaccines are considered.

Measles elimination: progress and challenges.

The accelerating progress in reducing measles incidence and mortality in many parts of the world has led to calls for its global eradication during the next 10-15 years. Three regions have established goals of elimination of indigenous transmission of measles. The strategy used in the Americas of a mass 'catchup' campaign of children 9 months to 15 years of age, high coverage through routine vaccination of infants, intensive surveillance and follow-up campaigns to prevent excessive build-up of susceptibles has had great success in reducing measles transmission close to zero. However, while these developments are impressive, much remains to be done to reduce measles-associated mortality in western and central Africa, where less than half of children are currently receiving measles vaccine and half a million children die from measles each year. The obstacles to global measles eradication are perceived to be predominantly political and financial. There are also technical questions, however. These include the refinement of measles elimination strategies in the light of recent outbreaks in the Americas; the implications of the HIV epidemic for measles elimination, issues around injection safety, and concerns about the possibility that secondary vaccine failures will contribute in sustaining transmission in highly vaccinated populations. The global priorities are to improve measles control in low income countries, increase awareness among industrialized countries of the importance of measles, and conduct studies to answer the technical questions about measles elimination strategies.

Epidemiologic study of Guillain-Barré syndrome in children <15 years of age in Latin America.

In 1986, surveillance of acute flaccid paralysis (AFP) cases among children <15 years of age was implemented in Latin America as part of the initiative to eradicate poliomyelitis from the Western Hemisphere. Data on AFP, including Guillain-Barré syndrome (GBS), could be analyzed from a regional registry system and from specific GBS studies in seven countries. Between 1989 and 1991, 3112 cases of GBS were reported in Latin America, representing 52% of all nonpolio AFP cases. From the studies in seven countries, a total of 1527 GBS cases (49%) were studied, representing an overall annual incidence rate of 0.91/100,000 children <15 years old. Follow-up investigations showed a persistent muscular weakness at 60 days, 6 months, and 1 year after onset in 61%, 14%, and 10% of children, respectively. This study confirms that with the disappearance of polio, GBS arises as the most common cause of AFP.

National immunization days: experience in Latin America.

Organization of national immunization days (NIDs) in all countries in Latin America in which polio was endemic has been one of the key elements that led to the interruption of the circulation of the wild poliovirus in 1991 from the Americas. National initiatives for control or elimination of measles using similar strategies have emerged from the successful organization of NIDs for polio eradication and lead the way to the eventual global eradication of this major killer of children. The major reasons for the success of polio eradication in the Americas were the commitment of national authorities, well-defined strategies, sustainable effort, and the participation of all sectors of society.

Strategies for poliomyelitis eradication in developing countries.

Oral polio vaccine (OPV) delivered only through routine services does not appear to interrupt wild virus transmission in the developing countries. The experience in the Americas, which despite intensive surveillance has not confirmed any cases of paralytic poliomyelitis due to wild poliovirus since 23 August 1991, has shown the necessity of delivery of additional doses of OPV through mass campaigns targeted at all children under five years of age regardless of their previous immunization status and in special mop-up operations targeted at this same age group in areas categorized as at high risk of virus transmission, such as those that harbored the virus in the recent past. High-risk areas were determined by empirical observations, which were subsequently confirmed by molecular epidemiology which indicated the presence of several "reservoirs" that helped maintain transmission over several years. During mop-ups, OPV is delivered house by house. This paper discusses the rationale for the utilization of these strategies and outlines the phases for their preparation and evaluation, with illustrations from recent experiences with the last cases of paralytic poliomyelitis in the Americas.