The evolution of child health programmes in developing countries: from targeting diseases to targeting people.

Mortality rates among children and the absolute number of children dying annually in developing countries have declined considerably over the past few decades. However, the gains made have not been distributed evenly: childhood mortality remains higher among poorer people and the gap between rich and poor has grown. Several poor countries, and some poorer regions within countries, have experienced a levelling off of or even an increase in childhood mortality over the past few years. Until now, two types of programmes--short-term, disease-specific initiatives and more general programmes of primary health care--have contributed to the decline in mortality. Both types of programme can contribute substantially to the strengthening of health systems and in enabling households and communities to improve their health care. In order for them to do so, and in order to complete the unfinished agenda of improving child health globally, new strategies are needed. On the one hand, greater emphasis should be placed on promoting those household behaviours that are not dependent on the performance of health systems. On the other hand, more attention should be paid to interventions that affect health at other stages of the life cycle while efforts that have been made to develop interventions that can be used during childhood continue.

Cost-effectiveness of oral cholera vaccine in a stable refugee population at risk for epidemic cholera and in a population with endemic cholera.

Recent large epidemics of cholera with high incidence and associated mortality among refugees have raised the question of whether oral cholera vaccines should be considered as an additional preventive measure in high-risk populations. The potential impact of oral cholera vaccines on populations prone to seasonal endemic cholera has also been questioned. This article reviews the potential cost-effectiveness of B-subunit, killed whole-cell (BS-WC) oral cholera vaccine in a stable refugee population and in a population with endemic cholera. In the population at risk for endemic cholera, mass vaccination with BS-WC vaccine is the least cost-effective intervention compared with the provision of safe drinking-water and sanitation or with treatment of the disease. In a refugee population at risk for epidemic disease, the cost-effectiveness of vaccination is similar to that of providing safe drinking-water and sanitation alone, though less cost-effective than treatment alone or treatment combined with the provision of water and sanitation. The implications of these data for public health decision-makers and programme managers are discussed. There is a need for better information on the feasibility and costs of administering oral cholera vaccine in refugee populations and populations with endemic cholera.

PIP: The recent development of safe, reasonably effective oral cholera vaccines has made it possible to consider their use in situations where the risk of epidemic cholera is high. This article reviews the potential cost-effectiveness of the B-subunit killed whole-cell (BS-WC) oral cholera vaccine in both a stable refugee population and a population with endemic cholera. Baseline epidemiologic assumptions were applied to the standard populations to generate the expected morbidity and mortality levels for cholera and simple diarrhea; then, the net costs per case and per death averted by various interventions were calculated. In the population at risk for endemic cholera, the net costs per disability-adjusted life year (DALY) averted are considerably higher since incidence and access to health care are lower. In this population, mass vaccination with BS-WC vaccine is the least cost-effective intervention compared with the provision of safe drinking water and sanitation or with treatment of the disease. In the refugee population, the net costs per DALY averted are much lower since attack rates are higher and access to health care facilities is assumed to be 100%. In this population, the cost-effectiveness for vaccination is similar to that of providing safe drinking water and sanitation alone and less cost-effective than treatment alone or treatment combined with the provision of water and sanitation. Ultimately, the relative cost-effectiveness of an oral cholera vaccine will depend not only on its safety, effectiveness, and duration of protection against the El Tor biotype, but also on the feasibility of administering it to high-risk populations.

Epidemic cholera among refugees in Malawi, Africa: treatment and transmission.

Between 23 August and 15 December 1990 an epidemic of cholera affected Mozambican refugees in Malawi causing 1931 cases (attack rate = 2.4%); 86% of patients had arrived in Malawi < 3 months before illness onset. There were 68 deaths (case-fatality rate = 3.5%); most deaths (63%) occurred within 24 h of hospital admission which may have indicated delayed presentation to health facilities and inadequate early rehydration. Mortality was higher in children < 4 years old and febrile deaths may have been associated with prolonged i.v. use. Significant risk factors for illness (P < 0.05) in two case-control studies included drinking river water (odds ratio [OR] = 3.0); placing hands into stored household drinking water (OR = 6.0); and among those without adequate firewood to reheat food, eating leftover cooked peas (OR = 8.0). Toxigenic V. cholerae O1, serotype Inaba, was isolated from patients and stored household water. The rapidity with which newly arrived refugees became infected precluded effective use of a cholera vaccine to prevent cases unless vaccination had occurred immediately upon camp arrival. Improved access to treatment and care of paediatric patients, and increased use of oral rehydration therapy, could decrease mortality. Preventing future cholera outbreaks in Africa will depend on interrupting both waterborne and foodborne transmission of this pathogen.

PIP: An epidemiologic investigation of a 1990 cholera outbreak among Mozambican refugees in the Nyamithuthu camp in Malawi highlighted the challenges of providing adequate treatment and prevention in this setting. Between August 23 and December 15, 1990, 1931 cholera patients were admitted to the camp's intravenous (IV) treatment tent (attack rate, 2.4%); 28% were under 6 years of age. There were 68 deaths among these patients, for a case-fatality rate of 3.5%. 84% of patients for whom data were available had come to Malawi less than 3 months before the onset of illness and 52% were admitted for treatment within 16 days of camp arrival. 60% of the 40 cholera deaths investigated in detail involved children under 4 years of age (17% of total cases). Acute dehydration was the most common cause of death among the 63% who died within 24 hours of IV tent admission, suggesting delayed presentation and inadequate early rehydration. The remaining patients died from complications (e.g., infections with fever caused by prolonged IV use). In 2 case-control studies, cholera was significantly associated with placing hands into the storage container holding household drinking water (odds ratio, 6.0), obtaining drinking water from the river (odds ratio, 3.0), and eating leftover unheated cooked peas (odds ratio, 8.0). Toxigenic Vibrio cholerae O1, serotype Inaba, was isolated from patients and stored household water. Increased water rations and running water during cholera outbreaks are recommended to reduce contamination of stored drinking water during washing. More rapid referral to IV tents, administration of oral rehydration solution in addition to IV, quick removal or replacement of IV lines to prevent infection, and more attention to child cases also would reduce cholera mortality.

The public health aspects of complex emergencies and refugee situations.

Populations affected by armed conflict have experienced severe public health consequences mediated by population displacement, food scarcity, and the collapse of basic health services, giving rise to the term complex humanitarian emergencies. These public health effects have been most severe in underdeveloped countries in Africa, Asia, and Latin America. Refugees and internally displaced persons have experienced high mortality rates during the period immediately following their migration. In Africa, crude mortality rates have been as high as 80 times baseline rates. The most common causes of death have been diarrheal diseases, measles, acute respiratory infections, and malaria. High prevalences of acute malnutrition have contributed to high case fatality rates. In conflict-affected European countries, such as the former Yugoslavia, Georgia, Azerbaijan, and Chechnya, war-related injuries have been the most common cause of death among civilian populations; however, increased incidence of communicable diseases, neonatal health problems, and nutritional deficiencies (especially among the elderly) have been documented. The most effective measures to prevent mortality and morbidity in complex emergencies include protection from violence; the provision of adequate food rations, clean water and sanitation; diarrheal disease control; measles immunization; maternal and child health care, including the case management of common endemic communicable diseases; and selective feeding programs, when indicated.

Avoiding missed opportunities for immunization in the Central African Republic: potential impact on vaccination coverage.

Quantified in the study are the extent of missed opportunities for immunization and the potential increases in vaccination coverage and timeliness that could be achieved by using all health centre visits to administer childhood vaccinations in the Central African Republic. The data were collected during a national vaccination coverage survey of 642 children aged 12-23 months from three areas: rural, urban, and the capital, Bangui. Dates of all vaccination visits and other health centre visits were obtained from combined vaccination/health cards. Nationwide, 70% of all opportunities for valid measles vaccination were missed. Of these, 28% occurred at visits when at least one vaccine was given, while 72% occurred at other health centre visits. If there had been no missed opportunities to administer all vaccinations due when at least one vaccine was given, the coverage would have increased from 53% to 67% for the diphtheria-pertussis-tetanus series, from 54% to 70% for measles, and from 34% to 59% for all antigens. If there had been no missed opportunities at any visit, the corresponding increases would have been to 70%, 76%, and 65%. For measles, 46% of the potential increase depends on recognizing that an earlier dose of the vaccine was invalid and on revaccinating. Days-at-risk for measles (after the age of 270 days) would have been reduced by a mean of 74 days per subject with a health card had no opportunities been missed. The method used serves as a valuable adjunct to evaluations of missed opportunities based on exit interviews at health facilities.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: The Central African Republic in 1986 initiated an accelerated immunization program which became fully operational in 1988. As part of the program, a policy of vaccinating eligible children at all health facility contacts was adopted. National surveys conducted in 1985 and 1989 indicated that there had been a substantial increase in vaccination coverage, but that immunizations were not being given at all visits on a widespread basis. The authors quantify the extent of these missed opportunities for immunization and the potential increases in vaccination coverage and timeliness which could be achieved if all health center visits were used to administer childhood vaccinations in the Central Africa Republic. Study data were collected during a national vaccination coverage survey of 642 children aged 12-23 months from rural and urban areas as well as Bangui, the capital. Dates of all vaccination and other health center visits were obtained from combined vaccination/health cards. Analysis found that 70% of all opportunities nationwide for valid measles vaccination were missed. Of these, 28% occurred at visits when at least one vaccine was given and 72% occurred at other health center visits. If there had been no missed opportunities to administer all vaccinations due when at least one vaccine was given, coverage would have increased from 53% to 67% for the diphtheria-pertussis-tetanus series, from 54% to 70% for measles, and from 34% to 59% for all antigens. If there had been no missed opportunities at any visit, the corresponding increases would have been 70%, 76%, and 65%, respectively. For measles, 46% of the potential increase depends on recognizing that an earlier dose of the vaccine was invalid and on revaccinating. Days at risk for measles after the age of 270 days would have been reduced by a mean of 74 days per subject with an health card had no opportunities been missed.

Epidemic cholera during refugee resettlement in Malawi.

BACKGROUND: In June 1988 a cholera epidemic occurred in a Mozambican refugee population resettling in southern Malawi. METHODS: A case-control study was conducted to determine possible risk factors for disease. The characteristics of 48 refugee households with any member(s) hospitalized for suspected cholera were compared to 441 randomly sampled refugee households without hospitalizations. RESULTS: Vibrio cholerae 01 was isolated from 50% (5/10) of case-patient stool cultures. Having any water containers with > or = 10 T capacity was associated with a significantly lower odds of suspected cholera in households (adjusted odds ratio [aOR] = 0.02, 95% confidence interval [CI] : 0.003-0.12), as was having metal cooking pots (aOR = 0.3, 95% CI : 0.12-0.7), after adjusting for length of residence and socioeconomic status (logistic regression model). Households with two or more children < 5 years old were at markedly increased odds of suspected cholera (P < 0.0001). These results suggest that water containers and cooking pots served important preventive functions during this cholera outbreak. Young children may have contributed to cholera transmission, but the reason(s) remains undetermined.

La vigilancia en el programa ampliado de inmunización / Surveillance for the expanded programme on immunization

La vigilancia es la base de la práctica de la salud pública. En este artículo se examina la experiencia de la vigilancia en el Programa Ampliado de Inmunización (PAI). Los sistemas de vigilancia incluyen la notificación regular, la vigilancia centinela y la notificación comunitaria. Los datos de las actividades de vigilancia deben vincularse a los obtenidos con la supervisión, la evaluación de centros asistenciales, encuestas de población y la investigación de brotes, con objeto de proporcionar información para la planificación, ejecución, evaluación y modificación de programas. Al evaluar los sistemas de vigilancia se debe determinar la medida en que se usan los datos para formular políticas y mejorar programas, así como la simplicidad, exactitud, integridad, puntualidad y costo de los datos. La vigilancia de las enfermedades inmunoprevenibles ha evolucionado a medida que los programas han ido madurando, para monitorear el progreso hacia las metas de control de enfermedades. La adopción de las metas de reducir los casos de sarampión en 90 por ciento, eliminar el tétanos neonatal y erradicar la poliomielitis ha puesto de relieve la necesidad de disponer de sistemas de vigilancia efectiva de las enfermedades. Es necesario aprovechar esta oportunidad para promover el fortalecimiento de los sistemas nacionales de vigilancia de las enfermedades, a fin de convertirlos en instrumentos efectivos de prevención y control de enfermedades importantes para la salud pública (AU)

Double think and double talk.

The public health debate on population growth and child mortality continues, fuelled by the hypothesis that in allowing more children to survive until reproductive age, programmes such as the Diarrhoeal Diseases Control Programme of the World Health Organization contribute to long-term human misery by overburdening the carrying capacity of the planet. A significant part of the solution put forward is to withhold public health services to children in developing countries. This argument is here refuted on socioeconomic, ethical and humanitarian grounds. An alternative approach is offered, which takes into account the economic and social obligations of the industrialized nations.

PIP: Dr. Maurice King has predicted that Third-World societies will collapse as a result of their growing demographic entrapment. Although Dr. King acknowledges that a lack of economic connections is strongly related to entrapment, he fails to call for economic solutions or interventions aimed at increasing the carrying capacity of an ecosystem (which would also lead to economic growth and, thus, provide a prerequisite for slowing population growth). Instead, Dr. King proposes withholding support from child survival programs. Since the current mortality rate for children under 5 years old in least developed countries (150-300/1000 live births) is held in check by improved economic and social conditions as well as by child survival interventions, these public health measures only reduce mortality among 15-30% of all children. Therefore, preventing 50% of the deaths which now occur would only increase the population by 10%. Instead of asking children to bear the brunt of the problem, it would be more humane and reasonable to provide better family planning (FP) programs. Also, curtailing existing programs for child survival would only lead to an insignificant reduction in financial allotments as compared to those devoted to such activities as military support. In addition, Dr. King's argument that communities should make their own decisions about whether or not to accept proposed programs of international aid has 4 fallacies. 1) It is unlikely that communities would choose to sacrifice their children for the promise of a better tomorrow. 2) Decision-making implies having viable options. Offering a community a "decision" without offering the social, economic, and technological choices available in developed countries would be unjust. 3) If FP were the only possible alternative to entrapment, societies would have to limit couples to one child or no children. 4) Even if communities opted to withhold public health services which were safe and effective, it would be wrong for the world community to endorse such unethical behavior. Dr. King also misses the point that child survival strategies are also FP strategies (extended breast feeding, for example) and that the best interests of community development are served by better FP and by better health care for children, which are complementary rather than competitive. Dr. King is also incorrect when he maintains that children are receiving the highest priority. Defending the previously-neglected plight of children does not preclude searching for the best balance of developmental strategies for a particular country. Promoting development at the expense of children, however, is a radical position which upsets this balance.

La vigilancia en el programa ampliado de inmunización / Surveillance for the expanded programme on immunization

La vigilancia es la base de la práctica de la salud pública. En este artículo se examina la experiencia de la vigilancia en el Programa Ampliado de Inmunización (PAI). Los sistemas de vigilancia incluyen la notificación regular, la vigilancia centinela y la notificación comunitaria. Los datos de las actividades de vigilancia deben vincularse a los obtenidos con la supervisión, la evaluación de centros asistenciales, encuestas de población y la investigación de brotes, con objeto de proporcionar información para la planificación, ejecución, evaluación y modificación de programas. Al evaluar los sistemas de vigilancia se debe determinar la medida en que se usan los datos para formular políticas y mejorar programas, así como la simplicidad, exactitud, integridad, puntualidad y costo de los datos. La vigilancia de las enfermedades inmunoprevenibles ha evolucionado a medida que los programas han ido madurando, para monitorear el progreso hacia las metas de control de enfermedades. La adopción de las metas de reducir los casos de sarampión en 90 por ciento, eliminar el tétanos neonatal y erradicar la poliomielitis ha puesto de relieve la necesidad de disponer de sistemas de vigilancia efectiva de las enfermedades. Es necesario aprovechar esta oportunidad para promover el fortalecimiento de los sistemas nacionales de vigilancia de las enfermedades, a fin de convertirlos en instrumentos efectivos de prevención y control de enfermedades importantes para la salud pública (AU)

Publicado en inglés en: Bull. WHO. Vol. 71(5), 1993

Refugees and displaced persons. War, hunger, and public health.

The number of refugees and internally displaced persons in need of protection and assistance has increased from 30 million in 1990 to more than 43 million today. War and civil strife have been largely responsible for this epidemic of mass migration that has affected almost every region of the world, including Europe. Since 1990, crude death rates (CDRs) during the early influx of refugees who crossed international borders have been somewhat lower than CDRs reported earlier among Cambodian and Ethiopian refugees. Nevertheless, CDRs among refugees arriving in Ethiopia, Kenya, Nepal, Malawi, and Zimbabwe since 1990 ranged from five to 12 times the baseline CDRs in the countries of origin. Among internally displaced populations in northern Iraq, Somalia, and Sudan, CDRs were extremely high, ranging from 12 to 25 times the baseline CDRs for the nondisplaced. Among both refugees and internally displaced persons, death rates among children less than 5 years of age were far higher than among older children and adults. In Bangladesh, the death rate in female Rohingya refugees was several times higher than in males. Preventable conditions such as diarrheal disease, measles, and acute respiratory infections, exacerbated often by malnutrition, caused most deaths. Although relief programs for refugees have improved since 1990, the situation among the internally displaced may have worsened. The international community should intervene earlier in the evolution of complex disasters involving civil war, human rights abuses, food shortages, and mass displacement. Relief programs need to be based on sound health and nutrition information and should focus on the provision of adequate shelter, food, water, sanitation, and public health programs that prevent mortality from diarrhea, measles, and other communicable diseases, especially among young children and women.