IMMUNISATION TRAINING NEEDS IN MALAWI.

OBJECTIVES: The Malawi Ministry of Health (MOH) and its immunisation partners conducted a training needs assessment in May 2013 to assess the current status of immunisation training programmemes in health training institutions, to identify unmet training needs, and to recommend possible solutions for training of health workers on a regular basis. DESIGN: A cross-sectional, descriptive study. SETTING: Health training institutions in Malawi, a developing country that does not regularly update its curricula to include new vaccines and management tools, nor train healthcare workers on a regular basis. SUBJECTS: Researchers interviewed Malawi's central immunisation manager, three zonal immunisation officers, six district officers, 12 health facility immunisation coordinators, and eight principals of training institutions. RESULTS: All health training institutions in Malawi include immunisation in their preservice training curricula. However, the curriculum is not regularly updated; thus, the graduates are not well equipped to provide quality services. In addition, the duration of the training curriculum is inadequate, and in-service training sessions for managers and service providers are conducted only on an ad hoc basis. CONCLUSION: All levels of Malawi's health system have not met sufficient training needs for providing immunisations, and the health training institutions teach their students with outdated materials. It is recommended that the training institutions update their training curricula regularly and the service providers are trained on a regular basis.

Neonatal tetanus mortality in coastal Kenya: a community survey.

In a house-to-house survey in Kilifi District, Kenya, mothers of 2556 liveborn children were interviewed about neonatal mortality, especially from neonatal tetanus (NNT). The crude birth rate was 60.5 per 1000 population, the neonatal mortality rate 21.1 and the NNT mortality rate 3.1 per 1000 livebirths. The neonatal and NNT mortality rates were higher in boys than in girls. Neonatal tetanus was not associated with mother's age, parity, or history of previous child death. The majority of the children (72%) were adequately protected at birth against NNT; in those with documented protection NNT mortality was 0, in those with undocumented protection 1.2 and in other children 8.5 per 1000 livebirths. Other risk factors for NNT included home delivery, untrained assistance during delivery, unhygienic cord cutting and application of potentially infectious substances on the umbilical stump. The survey indicates that over the past decade the surveyed area has greatly reduced neonatal and NNT mortality. Possible strategies for accelerated NNT control have been identified by the survey.

Maternal tetanus: magnitude, epidemiology and potential control measures.

Maternal tetanus, defined as tetanus occurring during pregnancy or within 6 weeks after any type of pregnancy termination, is one of the most easily preventable causes of maternal mortality. It includes postpartum or puerperal tetanus resulting from septic procedures during delivery, postabortal tetanus resulting from septic abortion and tetanus incidental to pregnancy, resulting from any type of wound during pregnancy. This review of published and unpublished hospital and community studies concludes that between 15,000 and 30,000 cases of maternal tetanus occur each year. Complete coverage of reproductive-aged women by tetanus toxoid is the most cost-effective way to eliminate this often neglected cause of maternal death.

Safety, effectiveness and ease of use of a non-reusable syringe in a developing country immunization programme.

Unsterile needles and syringes may transmit blood-borne infectious agents such as HIV and hepatitis B virus. The emergence of these diseases as major public health concerns and the risk of nosocomial transmission has heightened interest in the development of single-use injection devices. WHO and UNICEF embarked on a programme to develop and introduce these devices in 1987. We report on a field trial in Karachi, Pakistan, of the SoloShot (SS) plastic disposable syringe, which has a metal clip in the syringe barrel to prevent second-time withdrawal of the plunger. A conventional disposable syringe (CS) was used as a comparison. We observed 48 vaccinators giving 2400 injections with the SS and 1440 with the CS; 98.7% of SS performed as designed. The average volume required per delivered dose was comparable for the two syringes and was delivered more quickly with SS. Training and experience had a small but statistically significant effect on several aspects of SS use. Vaccinators who indicated a syringe preference preferred SS on 7 out of 9 indicators. SS is safe and effective in preventing reuse and is easier and quicker to use than the CS. Vaccinators require little, if any, special training. It could directly replace disposable syringes in expanded programmes on immunization (EPI) in countries where use of unsterile disposable devices occurs or when sterilization is not practical.

PIP: The emergence of HIV and hepatitis B as major public health problems and the risk of nosocomial transmission demands that syringes and needles either be used one time and disposed of or reused only after thorough sterilization between patients. The World Health Organization and UNICEF launched a program in 1987 to develop and introduce single-use injection devices. Even so, incorrectly sterilized syringes and needles as well as disposables are frequently reused. Alternatives to existing injection devices are therefore clearly needed. The authors report on a field trial in Karachi, Pakistan, of the SoloShot (SS) plastic disposable syringe, which has a metal clip in the syringe barrel to prevent second-time withdrawal of the plunger. The use and acceptance of the SS was compared against that for the conventional plastic disposable (CS) syringe routinely used by the Expanded Program on Immunization in Pakistan. The SoloShot permits a single filling and emptying, after which a metal clip locks the plunger to prevent it from being drawn back a second time. A breakaway notch in the plunger inhibits twistout, while a barrier rib on the plunger guards the clip against intentional defeat. The metal clip is set to permit filling up to 0.575 ml of vaccine with an head space to allow the removal of air bubbles and adjustment for the exact dose. The clip is never in contact with the vaccine liquid. Researchers observed 48 vaccinators giving 2400 injections with the SS and 1440 with the CS. 98.7% of the SS performed as designed. The average volume required per delivered dose was comparable for the two syringes, but was delivered more quickly with the SS. Training and experience had a small but statistically significant effect on several aspects of SS use. Vaccinators who indicated a syringe preference preferred the SS on seven out of nine indicators. One may conclude that the SS is safe and effective in preventing reuse and is easier and quicker to use than the CS. Vaccinators require little, if any, special training. These encouragingly positive findings suggest that the SS could directly replace the CS in expanded programs on immunization in countries where the use of unsterile disposable devices occurs or when sterilization is impractical.

Prevalence, incidence, and epidemiological features of poliomyelitis in the Yemen Arab Republic.

There is a lack of reliable information on the extent of the poliomyelitis problem in developing countries, although the disease is thought to be more of a threat in urban than in rural areas. The Expanded Programme on Immunization (EPI) began operations in Yemen in 1977, and it was considered appropriate to try to establish the prevalence of residual paralysis due to poliomyelitis in children aged 5-13 years, in order to estimate the annual incidence of clinical cases of the disease, and to determine the epidemiological features of poliomyelitis in the country. The data thus obtained would provide a basis for assessing the impact of the immunization programme on the incidence of poliomyelitis.The results of the survey showed a prevalence of lameness due to poliomyelitis of 4.0 per 1000 children. The estimated annual incidence of the disease is thus 18.6 per 100 000 of the general population, or approximately 1088 cases each year, with an estimated 163 deaths. An estimated 5000 children aged 5-13 years are lame as a result of poliomyelitis. There was no significant difference in the incidence of the disease in rural and urban areas. The median age of onset was 1.92 years in the urban setting and 1.29 years in the rural setting, with more than half of all cases occurring before the age of 2 years. Immunization efforts should therefore be directed towards infants aged under 2 years. Although a national disease notification system was established in 1976, 95% of the clinical cases discovered during the survey had not been reported. This underlines the importance of special surveys in gathering the data necessary to evaluate the effectiveness of the immunization programme.

Role of health communications in Russia's diphtheria immunization program.

As part of a broader program in health communication assistance, project staff from Basic Support for Institutionalizing Child Survival worked with staff from Russia's oblast (regional) public health agencies to design and implement communication activities supporting local diphtheria immunization efforts. Because aggressive community outreach efforts and strong administrative sanctions had already achieved impressive adult coverage rates for first doses of diphtheria toxoid vaccine, communication interventions emphasized the need for second and third doses. Outcomes were assessed through vaccination coverage data and more qualitative measures. In one project site, the increase in adult coverage (two or more doses) was very modest. In a second site, with a stronger communications component, coverage increased significantly (from 20% to 80%). Although it is not possible to disentangle completely the effects of communications from other aspects of oblast immunization programs, these and other outcome data suggest that health communications can play an important role in Russia's ongoing mass immunization efforts.

Successful control of epidemic diphtheria in the states of the Former Union of Soviet Socialist Republics: lessons learned.

Epidemic diphtheria reemerged in the Russian Federation in 1990 and spread to all Newly Independent States (NIS) and Baltic States by the end of 1994. Factors contributing to the epidemic included increased susceptibility of both children and adults, socioeconomic instability, population movement, deteriorating health infrastructure, initial shortages of vaccine, and delays in implementing control measures. In 1995, aggressive control strategies were implemented, and since then, all affected countries have reported decreases of diphtheria; however, continued efforts by national health authorities and international assistance are still needed. The legacy of this epidemic includes a reexamination of the global diphtheria control strategy, new laboratory techniques for diphtheria diagnosis and analysis, and a model for future public health emergencies in the successful collaboration of multiple international partners. The reemergence of diphtheria warns of an immediate threat of other epidemics in the NIS and Baltic States and a longer-term potential for the reemergence of vaccine-preventable diseases elsewhere. Continued investment in improved vaccines, control strategies, training, and laboratory techniques is needed.