Immunization : a chance for every child

Cover: Sheltered against the ki ller diseases of childhood. World Health Day poster designed by Peter Davies and contributed by the International Green Cross, Marburg. IX ISSN 0043-8502 World Health is the officia l ill ustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor : Pete r Ozorio World Health appears ten times a year in English, French, German, Portuguese, Russian and Spanish, and four times a year in Arabic and Farsi . Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necess- arily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents A chance for every child by Halfdan Mahler . . . . . . . . . . . . 3 EPI : "shots" that save lives by Ralph H. Henderson . . 4 Six killers of children . . . . . . . . . 7 Room for expansion by Donald Allan . . . . . . . . . . . . . . 8 One million children with a chance to live UNICEF's James P. Grant interviewed by Jack Ling . . . . . . . 10 The cold chain . . . . . . . . . . 13 Vaccines versus disability by Sir John Wilson .. . . .. .. : . . . 14 A chance for every child . . . . 16-17 An element of primary care by Leo A. Kaprio . . . . . . . . . . . . . . 18 Motivating parents by Mohammad llyas Burney and Faiyaz Ahmed Lari . . . . 19 Islands in the sun by Henry C. Smith 21 New vaccines . . . . . . . . . . . . . . . 23 Children-power in Mexico Photo-story by Liba Taylor . . . . 24 Smallpox showed the world the way by John F. Wickett. . . . . . . . 26 Immunization milestones . 28 News Page . . . . . 30 2 Many heads of state have taken the lead in immunization. President Kenan Evren of Turkey took a hand in giving oral polio vaccine to babies to publicise a nationwide campaign! 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W oRLD HEALTH, Jan./Feb. 1987 IMMUNIZATION a chance for every child WORLD HEALTH DAY, 7 April, commemorates the coming into force of WHO's Constitution, in 1948. This year, countries around the world will use World Health Day to spotlight their activities in immunization by Dr Halfdan Mahler Director-General of the World Health Organization [!] We have-within our reach-a challenging goal set in 1977 by the health parliament of nations, our World Health Assembly , to provide immu- nization for all the children of the world by 1990. There is, however , no room for compla- cency. I have decided to devote World Health Day 1987 to immunization because much more still needs to be done within countries themselves. No matter how generous external support will be , nothing can replace the active participation of indi- viduals and their communities , of national leaders and their government structures. Planet Earth can no longer accept that, in the age of modern technology, children should st.ill die by the millions of dis- eases which can be prevented by available .vaccmes. Since we launched the WHO Expanded WORLD HEALTH, Jan./Feb. 1987 Programme on Immunization in 1974, moving forward with the strengthening of primary health care , there have been major public gains. The lives of some 800,000 infants are saved every year in developing countries, where child, vaccine and health worker can be brought together. The World Health Organization is particularly grateful to UNICEF, whose active support to achieve universal child immunization by 1990 has been and will remain of critical importance for the success of this programme. To offer the chance of a lifetime to all the children of the world will call for the informed cooperation of the people, the unwavering commitment of leaders, the devotion of health workers , the loving care and intelligent interest of parents, and the raising of the necessary funds and materials. Immunization is truly -a chance for every child. 3 EPI: "shots" that save lives Six diseases have two features in common: they kill young children-but children can be vaccinated against them. These are the target diseases of WHO's Expanded Programme on Immunization. And the target date is the year 1990 by Ralph H. Henderson In the industrialised countries of the world, some 985 out of every 1,000 chil- dren born will live to enjoy their fifth birthday. In some parts of the Third World, not far short of 500 out of each 1,000 will die before they are five years old. There is no single reason for this annual holocaust among the babies of the Third World-and no simple solution. Many will die from infections caused by unhygienic practices at birth, many more from chronic mal- nutrition, or from chronic diarrhoea caused by insanitary conditions at home and contaminated drinking water. Very often these conditions may all afflict the baby at the same time, and may be coupled with malaria and other infectious or parasitic diseases of hot tropical countries. But six particular diseases share two outstanding features in corn- m on; they kill young children- and young children can be protected against them by vaccinations. These six are the target diseases of WHO's Expanded Programme on Immuni- zation (EPI), and of UNICEF's Univer- sal Childhood Immunization (UCI); measles, poliomyelitis, diphtheria, pertussis (whooping cough), tetanus and tuberculosis. The smallpox experience It was on the heels of the dra- matically successful campaign to eradicate smallpox that WHO's Ex- panded Programme on Immuniz- ation set its target in 1977. In many ways the two programmes are quite different. Smallpox was conquered, not so much through mass vaccina- tion of all the world, but by being backed into a corner every time it raised its head; the moment a case appeared, a mobile health team visited the locality and vaccinated everybody, so that the infection was no longer transmitted. Finally the last little pockets of resistance were wiped out. But the EPI diseases cannot be so easily cornered, and not all of them have the potential for eradication. They can be controlled, . however, protecting millions of children and increasing their chances to live be- yond that critical fifth birthday. (Beyond that age, children are gen- erally fitter, and better able to with- stand infections.) Because the EPI diseases strike young, immunizations must reach children early in life to be protec- tive. To achieve high coverage, and to do this on a continuing basis, requires that whole communities be actively involved. The task is to ensure that every newborn child is identified and brought to the health services promptly, and that return visits are made until all the needed immunizations are complete. As with smallpox, the actual de- livery of the vaccine "jab" does not require a physician: village health workers, given proper training and supervision, do a fine job. The EPI vaccines are not as resis- tant to heat as was the smallpox vaccine, so they need to be safe- guarded by an effective "cold chain." It sounds simple. Every phial of vaccine has to be kept at a fairly constant temperature from the factory to the means of interna- tional transport, to the national storage point, to the local transport, Grave of a baby in southern Africa. Many such early deaths can be pre- vented by immunization against child- hood diseases. Photo N. Durreii-McKenna © WoRLD HEALTH, Jan./Feb. 1987 to the village or community storage point, and to the arm or backside of the child. But this "chain" has to be foolproof: it has to guard the vac- cines against missed aircraft con- nections, long spells on the dock alongside a ship, storage in a ware- house in a country whose electricity supply may be subject to sudden interruptions, or hours of bumping along a dirt track in an icebox strapped to a health worker's bicycle. So developing the cold chain has really called for a lot of ingenuity and inventiveness. We now have a considerable number of "gadgets" that are all playing their part in keeping vaccines cool and active. In turn these gadgets-refrigera- tors, iceboxes, easily-read ther- mometers, vaccine-testing appar- atuses-have to be maintained, often in remote communities. So the people who will use them have to be trained in maintenance and simple repairs. A sense of urgency pervades EPI. The goal is to provide immuniz- ations for all children by 1990, but 1987 still finds us only about half- way there. Acceleration in recent years has been rapid, but must continue apace. There are two com- plementary needs: social mobili- sation to make the service avail- able, and better management to make those services effective and attractive to mothers. Social mobilisation has been re- cognised by UNICEF and an increas- ing number of other partners in EPI as being critical to the acceleration efforts now underway. Immuniz- ation is becoming big news in many countries, with heads of state, re- . ligious leaders and celebrities all becoming personally involved with getting the children of their coun- tries immunized. Sometimes an in- tensive national campaign is used at Immunization -when early protection is a must- Age Vaccine Birth BCG, oral polio 6 weeks OPT, oral polio 10 weeks OPT. oral polio 14 weeks OPT, oral polio 9 months Measles WoRLD HEALTH, Jan./Feb. 1987 Severe malnutrition in the Eastern Mediterranean region. Neither mother nor child aFe in a condition to withstand the added burden of an infectious disease. Below: A life-saving drop of anti-polio vaccine finds its target in Latin America. Polio could soon /be a thing of the past throughout the Americas. Photos WHO/F. Perabo and Keystone/L Pinto/0 Globo © 5 6 EPI: "shots" that save lives the start, involving large segments of the society. Sometimes a more gradual approach is used, beginning with limited geographic areas but moving surely and swiftly to cover the entire population. Social mobilisation will falter un- less it is backed up by good health services. Health staff need better training and supervision to provide reliable and convenient services with minimal waiting times. Staff need to be able to inform mothers about expected reactions after im- munization and to ensure they understand the need to return to complete the immunization series. A particular challenge lies in the big cities. Newcomers arriving from the countryside need protection for their children in the crowded condi- tions that are often their lot. They may be alienated from everything "official," including the health ser- vices. Special campaigns may be required to "catch" them. While efforts are being made to solve problems with current tools, research is forging ahead in the quest for new vaccines which will simplify the immunization proce- dure and give even more complete protection to every child. All this costs money. Pro- grammes have been able to im- munize an infant for as little as US $5 to $15, but such figures will vary widely from country to coun- try, depending on local geography, the state of the health services, the accessibility of vaccines, and the "health" of the national economy. At present, some $500 million is being spent each year globally in the Programme, 80 per cent of it by developing countries themselves. Inevitably, EPI must rely firstly on the continuing political will of WHO's member countries, but also on the goodwill and eagerness of a great army of staff workers and volunteers in non-governmental or- ganizations, charities and religious institutions. Together, we can achieve the 1990 goal of EPI and make a great stride forward towards the longer-term goal of Health for all by the year 2000. • Babies sprawl asleep at the feet of their begging mother. Unvaccinated, they are defenceless against diseases that prey on young children. Photo W HO/P. Almasy' W o RLD HEALTH , Jan ./Feb. 1987 S · x k ·ners o · cl ·ldren Poliomyelitis W oRLD HEALTH, Jan./Feb. 1987 Every 15 seconds a child dies from measles : two million children die each year . Virtually every unpro- tected child will contract the dis- ease. which may be fatal for those already weakened by malnutrition or chronic diarrhoea. Complications occur in about 30 per cent of cases, and include ear infections, diar- rhoea. blindness. and encephalitis. Diphtheria kills between 1 0 and 15 per cent of its victims. lt causes membranes to develop in the throat. and death may follow from asphyxiation. Diphtheria bacilli in the throat also produce a toxin which. in the bloodstream. may attack the heart or nervous system with fatal results . Some 51 million children contract pertussis (whooping cough) every year; over 600,000 of them die from . it. The disease got its com- mon name from the "whoop" chil- dren make while desperately trying to inhale after coughing spasms. Complications include : malnutri- tion (due to excessive vomiting after coughing), permanent brain damage and pneumonia. Neonatal tetanus is estimated to cause 800.000 deaths a year . Near- ly 1 00 per cent of newborn babies who get it will die. lt is caused by unsterile methods of cutting the umbilical cord or by applying germ- laden substances to the stump. Immunization of the mother will give protection to the baby. Annually, about 275,000 children are affected by poliomyelitis. lt is the major cause of lameness in the Third World. where nearly all chil- dren get polio before they are three. Although only one out of every 200 infected children de- velops typical symptoms. among those with recognised polio, one in ten will die . Tuberculosis attacks as many as ten million victims a year, and is particularly lethal for infants . In the lungs, TB can trigger a rapidly fatal pneumonia or a slow wasting disease. In the bone, it can lead to severe deformities . When TB occurs in the brain , the results are usually fatal. Pertussis 7 0 :r: s Ul 0 0 .!:: ()._ Root for expansio 1 In 1987, some $500 million is being spent on EPI, or about what the world spends on armaments every six hours! But double this amount will be needed to finish off the job I ',~ ,J f~~£~~~~~~E~1~~ world. By 1974, however, it was estimated that no developing country had exceeded even five per cent coverage for all six EPI target diseases. For lack of adequate reporting, many countries did not recognise the seriousness of the problem. Clearly a major new campaign was needed. At the World Health Assembly in that year, Dr H.-G. Kupferschmidt, of the German Democratic Repub- lic, urged that "the experience by Donald Allan gained in the smallpox eradication programme and the personnel em- ployed in it should be used in the control of other communicable diseases, such as measles, polio, tetanus and tuberculosis, from which millions of children die in developing countries." Professor J. Kostrzewski of Poland proposed the launching of "an expanded pro- gramme of immunization in every country." The Assembly responded by call- ing on WHO to develop immuniz- ation programmes and to increase the availability of inexpensive, good-quality vaccines to develop- ing countries. EPI was on its way. It became a full-fledged programme in 1977, when the 1990 target date for immunizing all the world's chil- dren was chosen. In that year too the first WHO courses to train national managers were given. An important lesson of the smallpox campaign was that health personnel ·needed to be taught new management skills in Another small child goes to an early grave. This pathetic scene is being re- peated daily around the world. EPI is striving to save many of these lives. Photo WHO/P. Almasy order to take the big step in scale from routine to expanded im- munization-to integrate the con- tributions of many branches of gov- ernment and to involve all levels of the community in campaigns. " Expanded" in the WHO defini- tion meant adding more disease- controlling antigens to vaccination schedules, extending coverage to all corners of a country and spreading services to reach the less privileged sectors of society. It meant concen- trating on immunizing babies dur- ing the first year of life and reaching mothers with convincing messages to assure their cooperation. National immunization days have proved effective in galvanis- ing all levels of society, from top politicians to celebrities, journalists, teachers and clergy, to attain a goal and raise public understanding. Such campaigns in Brazil lowered polio rates from 3,596 cases in 1975 to under 100 since 1979, and in Colombia from 576 in 1981 to 24 in 1984. The challenge is to assure that such days are designed to rein- force, not replace, the primary health care services that must pro- vide immunization on a regular basis to young children. The "cold chain" plays a vital role, keeping vaccines at tem- peratures below 8 Centigrade ( 46 Fahrenheit) and shielded from light, so that they don't lose their poten- cy. If a breakdown in the cold chain goes undetected and children become infected with a disease because their vaccination was worthless, the entire health service loses credibility among the local population. In 1987, only about US $500 mil- lion is being spent on EPI-about what the world spends on arma- ments in six hours. This needs to double by 1990. And the flow of donations is indeed rising. Rotary International has pledged $120 mil- lion for polio vaccines. The Arab Gulf Fund, the Sasakawa Health Foundation and the bilateral aid agencies of more than a dozen industrialised nations, the World Bank, UNDP, and UNICEF have all increased contributions to immu- nization programmes. "No country with a realistic EPI plan of operations needs to be con- strained by a lack of vaccine, cold chain equipment or supplies," WHO's Director-General, Dr Halfdan Mahler, reported last year. The WoRLD HEALTH, Jan ./Feb. 1987 Test-firing of a military missile with the potential to carry out a nuclear war- head. Arms spending surpasses the annual cost of EPI every six hours. Photo L. Sirman © most serious bottleneck today, he said, is "management capacity within national programmes" . Even though WHO courses have trained more than 20,000 EPI man- agers and workers, and national adaptations of WHO materials have helped to train at least another 350,000, acceleration of EPI re- quires more skilled manpower. Some countries in Africa and the Middle East are facing severe dif- ficulties and may not make the 1990 target, says Dr Ralph Bender- son, EPI's Director at WHO head- quarters in Geneva. These are the ones burdened by war, famine or extreme poverty of resources. Still others will probably need expatri- ate staff to supplement national human resources for quite a few more years. And in some develop- ing countries the health establish- ment needs to unbend and recog- nise the importance of involving non-medical community personnel to increase popular participation. But already officials of the Pan American Health Organization are predicting that poliomyelitis will be banished from South America by 1990. Chances are good that polio will be virtually eradicated world- wide by the end of the century. Improved vaccines, equipment and methodologies give promise that the five other diseases can be brought under control on schedule. "If everybody decides 'We're going to do it,' it will be done," says Dr Henderson. The aim of EPI is to provide immunization for every child. But even if only 80 per cent get full protection, the six diseases will for all practical purposes be on their way to oblivion. • 9 One million children ·with a .chance to· live, 10 Mr )ames P~ Grant, Executive Director of the UN Children's FundjuNICEF) was ihter- viewed for World Health by Mr Jack Ling, Visiting Professor of Communications, Uni- versity of Southwestern Louisiana, USA JL: At the World Health Assembly in 1978, the interna- tional community adopted a resolution setting a specific target for WHO's Expanded Pro- gramme on Immunization (EPI). This was to protect all children, by 1990, against polio, diphtheria, per- tussis, tetanus, measles, and tuber- culosis. As a close collaborator with W,HO in primary health care (PHC), including immunization, what is UNICEF's support towards this goal? JPG: We try to support it on sev- eral different fronts. One is to add credibility to the goal and commit UNICEF's resources to achieving it by that date. Secondly by advocacy -and advocacy at a number of different levels- telling the world loudly that universal immunization for all children by 1990 is an achievable goal, and persuading top leadership to support ministries of health in their efforts. Thirdly, we provide financial assistance for vac- cines, syringes, transport, the cold chain and other aspects. Finally, we are very active in providing the "software," particularly mobilis- ing the whole range of ministries and NGO that are required for a successful end result. Universal Child Immunization, UCI, can be achieved only when immunization as part of PHC is accepted as a goal of all sectors in society, and is not just left to the responsibility of the ministries of health. JL: You mention UCI while WHO's programme is called the Expanded Programme on Immunization. Is there a difference between them? JPG: Absolutely none. EPI is the instrument for UCI. JL: How crucial is immunization to the overall UNICEF programme of collaboration with governments? JPG: It's an increasingly important part of our collaboration with de- veloping countries, primarily be- cause in recent years we have seen this potential to accelerate EPI and achieve dramatic results through social communication to a degree . that we had scarcely anticipated before 1982. The PHC concept, as enunciated in the 1978 Alma-Ata Declaration, worked! It was possi- ble to treat health care as an effort embracing all sectors, and to mobil- ise these sectors at very low cost to support immunization. So this ac- tivity moved higher on the UNICEF WoRLD HEALTH, Jan./Feb. 1987 list of pi-iorities for support and funding. Vaccine use alone trebled between 1983 and 1985. At the moment, expenditures have in- creased to about 11 per cent of UNICEF's budget and can be expected to increase further until 1990, after which expenditures should decrease as EPI shifts more to maintenance. It is noteworthy, however, that the "twin engines" of immuniza- tion and oral rehydration therapy (ORT) which propel and accelerate PHC and child survival take only about half as much money as we are spending on water supply activities. And our expenditures on PHC, ex- clusive of EPI and ORT, are larger today than they were in the early 1980s. JL: You are saying that financial input is not necessarily an accurate measure of UNICEF's contribution? JPG: That's right. What we are seeing are greatly increased inputs by government into these areas, either in absolute amounts for PHC or through a restructuring of their budgets. For example, in Pakistan they delayed the building of the big, new capital hospital in Islamabad for several years, and took the savings from there to finance their national immunization programme, the oral rehydration programme, and the retraining of tens of thousands of traditional birth atten- dants over a three-year period. Expenditure by bilateral agencies is also going up substantially in this arena. The United States Agency for International Development (USAID) has received from Congress an extra $80 to $100 million a year over the past three years to support PHC, including these child survival activities and, of course, UCI. And the Italian Government has made $100 million available to us for Africa, primarily to be devoted to advancing Immunization and oral rehydration-but particularly UCIIEPI-in 26 African countries. · JL : How do you assess the progress so far and what are the problems between now and 1990? JPG: I would say that we-meaning the world community, WHO and UNICEF and the governments con- Inadequate sanitation breeds diseases. UNICEF, like WHO, sees immunization as an integral part of primary health care : a global strategy for better health. Photo W HO/Zafar W ORLD HEALTH, Jan./Feb. 1987 cerned-are more or less on track towards achieving that goal, pro- vided that the present level of polit- ical commitment can be sustained and backed up with the right kind of assistance for implementation. JL: Is there any hard evidence that the immunization coverage has contributed directly to reducing in- fant mortality? If X number of children are immunized, theoreti- cally there should be a correspond- ing reduction in infant mortality? Are there any countries where this has actually happened? JPG: These are obviously difficult things to measure. It has been easier to measure the impact of oral rehy- dration because that impact is seen almost immediately, so that in a country such as Egypt you can ob- serve a decrease in diarrhoea cases. In the hospitals it's possible to talk of scores of thousands of children's lives being saved. In immunization we, in consultation with WHO, have come up with a general estimate that the number of deaths from these six diseases has dropped from the early 1980s level of about four and a half million to something like three and a half million today. That is, nearly one million child lives a year are being saved as a result of the immunization programmes of the 1980s. JL: What other interesting, success- ful national experiences are worthy of attention? JPG: A country such as Colombia (one of the first to undertake an · accelerated EPI programme) gives a good illustration of both sustain- ability and expansion. The first year, the emphasis was really on alerting people to get children im- munized, using many thousands @f radio spots, television spots , having the president himself giving vacci- nations, and the like. Then atten- 11 One million children with a chance to live tion turned almost immediately to how to keep this drive sustained and how to broaden it. Several elements were quickly identified. One, of course, was that the health system itself, in carrying forward the successful 1984 effort, placed a whole new priority on immuniza- tion. So that within the health struc- ture there was a shift in emphasis. With success, there was a new spirit in the health ministry about what could be done. Then, there was a revamping of the primary school curriculum to include basic materials on immuniz- ation and on the other major ele- .ments of PHC. The other partners in the initial crusade also sought ways to institutionalise their works. The church set up a regular training programme for all parish priests, so that premarital counselling now in- cludes several minutes underlining that responsible parenthood in- cludes knowing about immunizing your children, how to prevent diar- rhoea, how to do oral rehydration therapy. Groups like the Red Cross included this whole broad range of PHC activities into their training programmes. So you see in Colom- bia an illustration of how a country went from a crusade into these other elements and on a more sus- tainable basis. In India, Prime Minister Rajiv Gandhi announced in May of 1985 that they would make "Universal Child Immunization by 1990" a living memorial to the late Mrs Indira Gandhi, a very worthy one indeed since about one million chil- dren a year have been dying in India from these six diseases. This was launched on Indira Gandhi's birthday of November 19, and seems to be proceeding well in India. Virtually all major countries in the world over the last 18 months have accelerated their programmes substantially towards the 1990 goal. China is dedicating itself to reaching it in all provinces by 1988. Nigeria has a well-developed pro- gramme to achieve UCI by 1990. Brazil in some ways ante-dated Colombia in social mobilisation, but it was focused initially just on polio and then they broadened it to cover the other major diseases. JL: How does UNICEF's child sur- vival and development revolution fit in with WHO's goal of Health for all by the year 2000, through PHC? 12 JPG: A historic watershed for health was Alma-Ata, when the concept of PHC was legitimised for the first time; and the subsequent vigorous pushing by WHO and UNICEF helped add to this legitimacy so that it now seems the proper thing to do. The country-by-coun- try follow up that WHO pursued with its Director-General Halfdan Mahler in the lead, and with Prime Minister Indira Gandhi and other leaders signing these PHC state- ments, gave a new legitimacy and urgency to the shift of attention towards preventing disease, to- Polio victim in Mexico. UNICEF and WHO are working hand-in-hand to prevent such tragedies. Photo WHO/L. Solmssen wards involving other sectors in health, and towards the need to find financially feasible ways for the health service delivery system to reach the village. So we saw the appearance of literally millions of auxiliary health workers after Alma-Ata as an extremely major development. The problem that we faced in the early 1980s was the impact of the global recession. Most governments began to restrict their investments on the social side. Education and health were cut back and this made it increasingly difficult to expand PHC and the more traditional medi- cal infrastructure at the same time. In many countries there was a real drying up of supplies, of financing. The Child Survival Revolution was designed to highlight the fact that there was a new capacity for social organization to make drama- tic progress in Health for all; so dramatic that it would become good politics for national leaders to in- vest significant amounts of their own leadership time in making it work, and in providing leadership and guidance to all sectors of so- ciety. The potentials for progress were also sufficiently great so that it was possible to energise non-health sectors of society, to excite non- governmental organizations about what could be accomplished, and to encourage community participation in immunization and oral rehydra- tion therapy. The Center for Disease Control in Atlanta, Georgia, points out that to add another year to male lives in the United States through curative means would take tens of millions of dollars, but that one could add at least ten years to the life of the average American male if through education he would stop smoking, watch the quality and quantity of his food intake, exercise regularly, and drink moderately. This pro- cess of change is already occurring. We see people stopping smoking, adopting different eating habits, taking up exercise, drinking much less-encouraged and motivated through different social channels. Now we are seeing in developing countries the same sort of motiva- tion against the old risks, and I look forward to the day when· the indus- trial countries will look at the ex- perience of Colombia and say 'that is the kind of total social mobilisa- tion we ought to apply in our coun- try against the problem of smoking, against the problem of alcohol.' These ought to be treated exactly as we are now attacking the six dis- eases through EPI and diarrhoea through oral rehydration therapy and health education. JL: You are saying that to get to Health for all, there is a need to mobilise all for health. Thank you, Mr Grant. • WoRLD HEALTH, Jan./Feb. 1987 The Cold Chain lfA all lfB all lf C an lfA & S&C &O au blue- · blue blue blue [!] The cold chain system is the lifeline of EPI, ensuring that potent vaccine arrives · at the right place, at the right time and in sufficient quantity. Temperature sensitive chemi- cal monitors (above) are attached to record cards in the national language and sent with the vaccine from point to point on the long journey from the manufacturer to the remotest health centre. The monitors change colour progressively each time the vaccine shipment is exposed to temperatures which are too high. The first step in the cold chain is at the vaccine supplier which manufactures, packs and labels the vaccine to WHO requirements , (above). High technical standards in cold chain management and equipment have to be maintained (UNICEF/UNIPAC exhibit on right). W oRLD HEALTH , Jan./Feb. 1987 The last storage point in the cold chain is often very remote. Special kerosene- driven refrigerators like the one on the right may be used to protect the vaccine from tropical heat, and to freeze icepacks used to cool vaccine during local transport to health centres. Special syringes, such as the single dose sterilisable plastic BCG syringe (left), have also been developed for EPI. 13 0 I s <n 0 0 .c Q_ Vacc· es versus dis bility Will the day ever come when people demand the right to be immunized against preventable diseases with the same pas- Sion with which they now demand the right to have a vote? by Sir John Wilson Listening recently to a recording I had made in an Asian vil- lage, I was surprised to find that the back- ground noise was not, as I had remembered it, temple bells, crows and the buzz of conver- sation, but coughing. You can dis- tinguish the staccato, hundred-day cough of pertussis, the dry perpe- tual cough of tuberculosis. As morbidity figures become av- ailable, it is increasingly evident that the diseases that are prevent- able by vaccines disable at least as many people as they kill. A recent survey of disabilities among mem- bers of a beggars' guild in India suggested that over half the impair- ments probably resulted from infec- tions acquired during childhood. A meeting of the Task Force on Child Survival (held in Cartagena, Colombia, in October 1985) esti- mated that 20 per cent of the world's disability would be pre- vented if WHO's Expanded Pro- gramme on Immunization were uni- versally implemented. These disabilities, building up year by year into massive "back- logs," constitute a major economic burden and a serious medical predi- cament for most developing coun- tries. They add a compelling devel- opmental argument to the case for implementing, and indeed further extending, the Expanded Pro- gramme on Immunization. The most obvious of these dis- abilities is poliomyelitis. You sel- dom see the worst cases because they have died or else are totally immobile. In almost any crowd in an Asian or African town you see the evidence of poliomyelitis: twisted bodies, arms rigid like 14 weapons, the "crawling cripples" who have learnt, through a kind of do-it-yourself rehabilitation to move with astonishing agility. The · estimate, some would say under-estimate, is that poliomyelitis annually paralyses some 250,000 children. In deprived urban com- munities, where the immunization coverage is often far below the claimed average of 40 per cent, Making music-and reading from a Braille score-at a school for the blind in Turkey. Measles is a prime cause of blindness and other disabilities. Photo WHO/C. Stauffer the extent of residual disability is usually far higher than that re- corded for pre-immunization com- munities in North America and Europe; the latter was estimated by Dr Sabin at 13,500 cases of paralys- ing polio for every 100 million of the population. The oral polio vaccine-because of its comparative ease of adminis- tration, the bonus of "herd immun- ity," and the fact that this disease has no animal reservoir-presents the possibility that, like smallpox, polio might be globally eradicated. Such an achievement would signifi- cantly change the pattern of disabil- ity in developing countries. Groups of disabled people, and adminis- trators who interpret the history of public health as a series of specific interventions, may sometimes find it difficult to understand why a campaign to eradicate polio-if that is indeed a practical possibility-is often seen as a deflection from general policy, rather than as a decisive step along the highway to universal childhood immunization and Health for all. Measles is an efficient killer of small children, but it is also a prime cause of blindness, deafness and some forms of mental handicap. Associated with vitamin A deficien- cy, it is a precipitating cause of xerophthalmia, the blinding mal- nutrition which is estimated by WHO to affect 500,000 children each year. In Central Africa, this form of blindness is known as the disease of the "three Ms": measles, malnutri- tion and muti (inappropriate local medicine) . Whooping cough is still a signifi- cant cause of death and disability. No-one who has seen the choking of a child from neonatal tetanus will doubt the lethal impact of this dis- ease; of the 15 per cent of children who survive a serious attack, many face a lifetime of disability. Tuberculosis is not only a signifi- . cant cause of disability amongst children, but is also probably. the largest single cause of impairment and incapacity amongst adults in developing countries. Beyond these target diseases of the Expanded Programme on Im- munization are other causes of dis- ability which could be controlled W oRLD HEALTH , Jan ./Feb. 1987 by immunization. it used to be believed that rubella (German measles) was not a significant prob- lem in Africa and Asia because the population has a high level of natu- ral immunity. This is now ques- tioned by the discovery that many children in special schools are blind from congenital cataract or else have multiple handicaps charac- teristic of congenital rubella. In West Africa, outbreaks of meningitis have added deafness to the predicament of many older vil- lagers who have been blinded by onchocerciasis (river blindness). Some 45 million people, mostly in the West ern Pacific Region, are es- timated to suffer from the chronic form of hepatitis which is likely to limit their working ability during part of their lifetime. Children at a training centre for the disabled in India. The diseases that are preventable by vaccines disable at least as many people as they kill. Photo Magnum/M . Franck © W ORLD HEALTH, Jan ./Feb. 1987 Conferences at Bellagio, Italy, in 1984 and at Cartagena, Colombia, in 1985 recorded remarkable pro- gress in mobilising resources for the global immunization programme. Technical and even financial limita- tions are being overcome; but the big hurdles are still a lack of moti- vation, the need to stimulate com- munity resources and the manage- rial talent of the private sector, afld the task of presenting immunization-not as an elitist bureaucratic requirement-but in terms which meet needs that are perceived by the community itself. In the belief that the prevention and relief of disability is such a per- ceived need, IMPACT (the interna- tional initiative against avoidable disablement) is promoting projects in which immunization will be com- bined with action against remedi- able disability. The first such project will begin shortly in Greater Bombay, India. In 40 zones of that city, it is esti- mated that there are 800,000 chil- dren requiring immunization and at least 75,000 blind, deaf, or physi- cally handicapped people who could have sight, hearing or move- ment restored by remedial surgery. It is hoped that the drama of this combined attack on present and future causes of disability will be one means of generating real com- munity involvement and continuity of action. The new generation of vaccines which are now being developed are likely to have a range in effective- ness which could change the whole future pattern of mortality and morbidity. The biochemical revolu- tion which has produced that possi- bility must now be matched by an equal revolution in communication and delivery systems. Will the day ever come when people will demand the right to immunization with the same pas- sion with which they now demand the right to vote? Will the next generation show the same en- thusiasm for eliminating viruses that past and present generations have shown for wiping out whole species of rare animals? Only time will tell. • 15 ~ t "' I 6 I ~ 0 0 _c "- a chance for · every c 16 Immunization offers the chance of a lifetime to children at risk from preventable childhood diseases. World Health Day, 7 April 1987, puts the spotlight on WHO's Expanded Programme on lmmunization-EPI Planet Earth can no longer accept that, in the age of modern tech- nology, children should still die by the millions from diseases which can be prevented by available vaccines. WHO's Expanded Programme on Immunization (EPI) - first estab- lished in 197 4- has as its goal to protect all the world's children against six killer diseases by the year 1990. Those diseases are: measles, poliomyelitis, diphtheria, pertussis (whooping cough), neo- natal tetanus and tuberculosis . A sense of urgency pervades the Programme, since this year finds it only about half-way towards that goal . Acceleration requires inten- sive efforts of social mobilisation to make available the necessary health services, and to inform com- munities and individuals about the protection that vaccines confer. Health staff will need more training to ensure that they provide reliable services with minimal waiting time, and that they know how best to motivate mothers to return with their babies to the clinic or health centre until the immunization series is completed. World Health Day this year will be marked in countries all around the globe by public events, health education campaigns and media announcements focusing on the lifesaving function of EPI. Immunization truly represents a chance for every chi ld. But offering children the chance of a lifetime requires more than publicity alone. The real challenge is to change social norms so that it becomes unacceptable for any child to be denied the benefits of immuniz- ation. • W oRLD HEALTH , Jan./Feb. 1987 <f) ·;::; c Q) (/) ~ 0 I ~ 0 0 _c "- :hild ... "' . , c '" (f) W oRLD HEALTH, Jan./Feb. 1987 Above: The health worker delivers a life- saving "jab" to a baby in Kenya. Below: The refrigeration units used in the cold chain have to be well maintained. Left : Research for still more effective vaccines. Below: The menacing dis- eases remain, but the baby is safely out of their reach. Under the watchful eyes of the pa- rents, the primary health worker vacdnates the baby. Now it is safe from the six diseases . .. . .. provided the vacdnes have been constantly kept protected against high temperatures. Below: The health centre's refriger- ator-a vital part of the cold chain. An element of primary care Immunization and the impetus of the Expanded Programme should lead to the .strengthening of health services as a whoie; EPI ought to be one building block in a permanent primary health care structure by Leo A. Kaprio [l] 'Programmes such as WHO's Expanded Pro-gramme on Immu-nization (EPI) are only one tool among many, all of which are necessary to improve the health of children and of the community in which they live. Without proper nutrition, clean water, shelter, basic sanitation and protection against many other dis- eases (like diarrhoea and acute res- piratory diseases) as well as first aid and treatment of common ailments, even the immunized infants might easily die soon and the community concerned might remain socially as desperate as it was before an im- munization programme. The aim of development in the health field should be to create a permanent health service, both curative and preventive, as envis- aged in the 1978 Alma-Ata Decla- ration of Primary Health Care. Accordingly, immunization and the impetus of the Expanded Pro- gramme should lead to the strength- ening of health services as a whole. Supported by both WHO and UNICEF, EPI represents an active form of social mobilisation to make people aware that their health conditions and their health services can be made permanently better and more effective. It is a great challenge to all health authorities and health workers to use this period between World Health Day 1987 and the 18 target year of 1990 to make this point. The primary health care ap- proach does not only aim to create a permanent network of health ser- vices. It also seeks to mobilise edu- cation, transport, agriculture, com- munications and industrial develop- In a photo taken some year~ ago, Brazilian schoolchildren lined up for the oral vaccine like a choir in full song. Today the vaccine is given during infancy. Photo Keystone!P. Moreira/0 Globo © ment to support healthy living by individuals, families and com- munities. Health workers can pro- vide the information that is needed in small, local communities to drive home the value of preventive health measures that will improve their health conditions. A permanent vacination service provided by health personnel must remain operational beyond 1990 and indeed beyond 2000. Even if one or two of the six (for instance, poliomyelitis or measles) can be eradicated from the world, many other new vaccines are already on their way. These too will need a structure of health services to ensure that they reach all the people and are both affordable and acceptable. Aware that in some developing countries primary care does not exist or is very weak, WHO has reminded those responsible at the international or national level that even an apparently successful im- munization campaign does not eliminate those social health prob- lems that are caused by a lack of services. Any health-related "spe- cial action" programme should be seen as one building block in a permanent service which embodies the several integrated elements of primary health care. Maternal and child health care is one good exam- ple, combining elements of nutri- tion, proper medical care of the mother, family planning, immuniz- ation, health education and so on as a primary " package" of services delivered by the polyvalent health worker. WHO's Director-General, Dr Half- clan Mahler, himself recommended in May 1986 that primary health care should be supported by district health care systems. Such systems can give technical, logistic and man- agerial support to the services of health centres, health posts and in- dividual community health work- ers, by pooling resources so as to increase the impact of health ac- tions, including immunization. Cooperation with other district level services can promote inter- sectoral co9peration at a level close to the people. , The targets for immunizations and methodologies to provide them may change and will change as some diseases become eliminated and as new vacc1nes are made wide- ly available. But immunization pro- grammes will always be a clear responsibility of the health services to protect our children against pre- ventable diseases. World Health Day 1987 reminds us all to be fully devoted to and mobilised in support of immunization as one of the most important activities to pro- mote health and build up healthy communities. • W oRLD HEALTH , Jan ./Feb . 1987 Motivating parents In some parts · of the Pakistan countryside, parents had tq be convinced that the injected vaccines were not some secret form of family planning which might make the women infertile by Mohammad llyas Burney and Faiyaz Ahmed Lari WoRLD HEALTH, Jan ./Feb. 1987 "Every child asks : Will you give me love, protection and immunization." With these words a bright- ly coloured poster issued by one of Pakistan's provin- cial departments of health seeks unashamedly to stir the feelings and sentiments of every parent. In effect the poster is saying: normal parental affection is not enough; it must be channelled into positive action that will support and sustain the child's life and well-being. Provincial health administrations and the federal authorities through- out Pakistan have encouraged post- ers, newspaper messages, radio and television announcements to propa- gate and publicise the immuniz- ation of children against six pre- ventable diseases of childhood. The government launched its Ex- panded Programme on Immuniz- ation (EPI) in 1979, coinciding with the International Year of the Child. The plan then was to protect 60 per cent of the nation's children aged under five by 1983 and 100 · per cent by 1987, and at the same time to consolidate and continue im- munizing new-born babies and preg- nant women. The result should be a 90 per cent reduction in the numbers of cases and deaths from the six diseases by 1990. In the event, the anticipated an- nual coverage was not achieved, and the progress made was mostly among the populations of cities and towns. So in January 1983 the gov- ernment launched a three-year Ac- celerated Health Programme (AHP) aimed at intensifying immunization of young children against the six target diseases. The objectives were quite specific: to protect nearly 15 million children aged up to five years and about seven million preg- nant women. The long-term targets were to reduce the numbers of cases and deaths by 90 per cent before 1990, and the anticipated benefits were to avoid seven mil- lion cases and 677,000 deaths. Two other components of AHP were the prevention of deaths from Feeding time in the queue for vacci- nations. Pakistan 's accelerated health programme puts great emphasis on motivating the community and, through the community-the parents. Photo W HO/P. Pa l mer 19 Motivating parents diarrhoea! diseases by using oral rehydration therapy (ORT) and community health education to alert the widest possible spectrum of the public to the value of EPI and ORT. Nevertheless, immunization re- mains the most important part of the programme, and accounts for 80 per cent of the US $42 million allocated-a tenfold increase on previous spending on EPI. The gov- ernment made facilities available to ensure better communications and to boost public motivation and community participation in the pro- gramme. A joint review team comprising 24 national representatives and 16 people from international bodies assessed the early progress and con- cluded that " on the basis of this review, we believe that the achievement of AHP in less than two years is remarkable." The team observed that "immunization coverage has risen rapidly, particu- larly in Punjab, where 80 per cent of the children are fully im- munized . . . The achievement in the North-west Frontier province is nearly as great and in other pro- vinces is also commendable." The improvements in the im- munization coverage were not uni- form throughout the country, nor were they permanent. After the campaign, most of the temporary employees could not be retained. As a result coverage declined, al- though not to the level existing before the campaign. Alerted by this decline, health authorities have taken action and are again increas- ing the health staff. While the logistics of vaccine and other supplies, competent man- power and managerial skills are all important, the community is re- garded as the most important ele- ment. The success of AHP depends on how the community is ap- proached and motivated, and how the community accepts and re- sponds to the programme. All the avenues of mass media are being harnessed, while visiting health teams made door-to-door house-calls and local religious lead- ers, teachers and village chiefs all cooperated in securing the max- imum possible public cooperation for the campaign. And through the community, the message reaches the parents. 20 In some parts of the countryside, parents had to be convinced that the injected vaccines were not some secret form of family planning, which would make women infertile and render the children sterile. Quite often the team manager would himself receive a shot of tetanus toxoid or take the oral polio vaccine to show that it was harm- less to health. One village refused vaccination because they were convinced that the pir-the local wise man with reputed spiritual powers-had drawn a barrier round the place so that no diseases could penetrate. When the EPI director went. along What's all this about needles? Tension in the waiting-room during an immuni- zation session. Photo WHO/C. Stauffer to visit the village, it happened that the pir was away from the village and some cases of measles had occurred. This made it much easier to convince the people to accept immunization. Since the myth of his "spiritual barrier" was broken, it was possible to immunize all the village children. There was strong resistance in another locality too. The deputy commissioner-head of the district administration-went along to add weight to the argument. Finally the local tribal chief agreed to have the youngsters immunized provided the deputy commissioner would de- clare on oath on the Holy Book (the Koran) that the same vaccines had been administered to his children as well. The official first checked that his children had indeed had all their "shots " and then was able to de- clare on oath that vaccines were good for children's health. The Accelerated Health Pro- gramme has given a new dimension to health education and motivation of communities. The national tele- vision network put out a pro- gramme called "Panic approach". This frankly dramatised the alarm- ing plight of non-immunized chil- dren who had breathing problems from diphtheria, suffered acute con- vulsions from tetanus, skin erup- tions from measles, emaciation from childhood tuberculosis, the acute spasms of whooping cough and the neuro-paralytic complica- tions of polio. One health centre in the capital city, Karachi, wa:s accustomed to having an average of ten people a day seeking vaccination. On the day after the television broadcast, nearly 3 ,000 mothers gathered at the centre with their babies and small children. There was a big management problem. Six immu- nization teams had to be formed on the spot, and all the children got their protection by late that same evening. Eight different films on the "Panic approach" theme were screened over the national TV network during the next six months. The next phase sought to attune viewers to the rewards of having a healthy baby. Besides 14 different films with this theme, television ran a popular puppet show under the title "Uncle Sarjam" aimed at child viewers, which conveyed simple health messages by way of satirical sketches and jokes. Parents too be- came interested. Today a network of 17 radio stations conveys the slogan of EPI and related messages throughout Pakistan in the languages of the people. Each carries at least five slogans or short announcements every day as well as a seven-minute talk about health every week. EPI centres have started up in hospitals, dispensaries, rural health centres, maternal and child health centres, or through outreach and mobile teams. The latter enable even very remote communities in sparsely populated areas such as Baluchistan to have the benefits of vaccination. And again local lead- ers, schoolteachers and religious chiefs play an important role in motivating parents to come forward and have their children protected for a lifetime. • W oRLD HEALTH , Jan./Feb. 1987 Islands iR the sun The success of EPI in the 19 countries of the English-speaking Caribbean plus Su- riname is fairly easy to measure. In 1979, only five countries had an immuni- zation coverage of at least 50 per cent with three doses of DPT among children under one year of age; and only two countries had achieved 50 per cent coverage with three doses of trivalent oral polio vaccine (TOPV). Seven years later, in 1985, 18 countries had achieved well over 50 per cent coverage with DPT and TOPV vaccines. Two countries could actually claim full coverage for both of these vaccines. In 1985, two other countries could also report full coverage with BCG immunization. To this protec- tion against tuberculosis, polio, diphtheria, pertussis (whooping cough) and tetanus was added the measles vaccine, but only gradu- ally, between 1980 and 1985. The six EPI diseases are kept under close surveillance to deter- mine what effect the immunizations have on the incidence of each of them, particularly by the Caribbean Epidemiology Centre (CAREC) in Port of Spain, Trinidad. A direct comparison over the years is not always possible, because disease re- W oRLD HEALTH, Jan ./Feb. 1987 by Henry C. Smith porting was not standard in past years. For instance, pertussis was not routinely reported to CAREC prior to 1981. But to give only two examples, the reported cases of Golden sands and waving palms in the sunshine: the Caribbean is a tourists' pa- radise but its children still need protection from dis- ease. EPI's progress can already be measured by a decrease in some infections. The 19 countries and territo- ries which share EPI informa- tion and experiences in the English-speaking Caribbean are: Antigua and Barbuda Anguilla · Bahamas Barbados · Belize Bermuda · British Virgin Islands Caym9n Islands · Dominica Grenada · Guyana Jamaica · Montserrat Saint Christopher-Nevis Saint Lucia Saint Vincent and the Grenadines Trinidad and Tobago Turks and Caicos Islands Suriname Photo W HO/E. Rice measles fell from 10,737 in 1981 to only 3,632 in 1985, and whereas 23 cases of diphtheria were notified in 1981, there were none in 1985. Poliomyelitis was not notified in those two years. But an outbreak with 58 cases occurred in Jamaica in 1982, when immunization cover- age was still low. It seemed that the disease was imported into a tourist resort area and then spread through the country. But these were the last cases of polio reported in the En- glish-speaking Caribbean. Tuberculosis cases of all types are reported together, so it is not pos- sible to tell if this disease is occur- ring among infants or children who have been immunized. Among the 19 countries mentioned, 13 do not offer BCG vaccine in their routine programmes. The goal of totally interrupting the indigenous transmission of wild poliovirus had already been achieved by 1982, and in 1985 there were no reported cases of diphtheria. Of course, intensive and sensitive surveillance with con- tinued high immunization coverage will have to be maintained in order to detect importations promptly and prevent re-transmission of these diseases. Tetanus (non- neonatal) and whooping cough are occurring at a rate of less than one case per 100,000 population. 21 There are several reasons for the steady progress of the EPI effort in the English-speaking Caribbean so far. Firstly, there is the commitment by governments to give maximum support to the programmes within the limits of their resources. UNICEF, USAID (the United States Agency for International Development), Rotary International and some other donors have provided some essential fund- ing, materials and equipment. National managers Each country has designated an EPI manager as the focal person responsible for carrying out and directing the programme on a con- tinuous basis. These managers meet every two years and discuss prob- lems they have encountered; re- source persons from the Pan Ameri- can Health Organization (PAHO) and WHO also join in the discussions and help to find possible solutions. The programmes are all inte- grated within the comprehensive health services, and are delivered from health centres as an essential component of maternal and child 22 health care. This ensures continuity, cost-effectiveness and convenience to the mother and child, so that total health care is offered from a single designated health centre or outreach clinic. The PAHOIWHO Revolving Fund through which vaccines are pur- chased has continued to ensure the reliability and quality of vaccines available to the programmes. In addition, the low cost and a simple system of payment have contri- buted to a more effective and in- creased immunization coverage. Evaluation is carried out annually to determine how effectively the cold chain and the recording and reporting systems are working at health centre level. In 1985, reports showed that 12 of the 19 countries had achieved over 75 per cent coverage with DPT and TOPV immunizations among children under one year of age. But the average immunization coverage with these two vaccines for children under one year of age in all 19 countries was 70 per cent. The more heavily populated coun- tries tend to achieve lower immuni- Islands in the sun Mothers-to-be in Trinidad respond to pleas to come for vaccination which will save their babies from tetanus. Photo WHO/E. Rice zation coverage than the smaller ones and this accounts for the low- ered average. As many as 15 per cent of child- ren who receive their first dose of DPT and TOPV do not return for the third dose. The countries which have solved or partially solved this problem seem to be those which encourage parents to bring their children for immunization early in life, and where there is routine health education through personal counselling of mothers and in groups at the health centres. The group counselling is also used to send messages or notes to those mothers and children who have missed their appointments. At one health centre, the nurse puts up the names of the defaulting mothers on her notice board. This seems to be . very effective, since the names which go on the board are few and far between. • WoRLD HEALTH, Jan./Feb. 1987 New vaccines [I] The Expanded Pro-gramme on Immu-nization (EPI) seeks to achieve universal childhood immuniz- ation by 1990 using vaccines which have all been avail- able for many years against six well-known diseases: diphtheria, whooping cough, tetanus, measles, poliomyelitis and tuberculosis. But advances in biotechnology have revolutionised this field. With- in the next decade, at least a dozen new or improved vaccines will reach the market. And many more vaccines are on the way. For health problems of the future, immuniz- ation will provide more and more solutions, and additional diseases may share the fate of smallpox: global eradication. The systems of vaccine delivery now used by the EPI will become increasingly im- portant as these new products become available. Why are the promises so bright? Within only the past few years, scientists have learned techniques which permit them to identify with great accuracy the substances (pro- teins) which are responsible for im- munity, and to synthesise antigens which induce the body to make antibodies which protect from the disease in question. Such antigens can be produced through chemical synthesis, but may also be produced by genetic engineering which al- ters micro-organisms so that they themselves become manufacturing plants. In fact, it is possible through genetic engineering to remove the portions of an organism which are responsible for causing disease, but to leave the portions which stimu- late a protective response from the body, turning disease organisms into vaccines. One micro-organism can be made to carry antigens from a number of different micro-organ- isms, permitting a single vaccine to protect against a number of differ- ent diseases. The doors to a whole new frontier have been opened. Work is in progress on four of the · vaccines currently used in the EPI: whooping cough, measles, polio W ORLD HEALTH, Jan ./Feb. 1987 and BCG (the vaccine against tuberculosis). Whooping cough (or pertussis) vaccine, while still ten times or more safer than the dis- ease, still causes an unsatisfactory number of side-reactions. One in about every 300,000 immuniza- tions results in lasting neurological damage. New purified vaccines, de- veloped initially in Japan, promise fewer reactions. They are currently undergoing field trials in Sweden. Because of interference from antibodies transferred by the mother, measles vaccination must be delayed for at least nine months after birth. This varies from nine months in developing countries (where measles frequently strikes Advances in biotechnology have en- sured a promising future in the field of vaccines. Photo WHO/J. Schytte during the first year of life) to 12 to 15 months in industrialised coun- tries (where the disease usually strikes older children). But recent observations have suggested that one particular strain of measles vaccine (the so-called Edmonston Zagreb strain) may protect children from four to six months of age. This would be a boon to all countries, and field trials to confirm these observations are already under way. Two excellent polio vaccines are available. The one in most common use is the oral (Sabin) vaccine. An inactivated vaccine (Salk) is also highly effective. The Sabin vaccine, however, is associated with paraly- sis in about one in a million vac- cinees. In communities with low or moderate immunization coverage, the Salk vaccine may be less effec- tive in controlling polio than the Sabin vaccine, and is several times more expensive. It may very soon be possible to synthesise a new vaccine which will be devoid of paralytic side-effects. BCG has had a chequered his- tory. It was given a severe blow from a recent trial in India, where little or no protective efficacy against tuberculosis in adults could be demonstrated during the first follow-up years, although more re- cent data suggest that there may be some protective effect in the lower age group. Recent studies in child contacts and case-control studies showed that BCG immunization of newborn babies clearly protects them from meningitis (with an effi- cacy of up to 95 per cent) and from miliary (disseminated) TB, but is not equally effective in preventing other forms of the disease. Tuber- culosis had suffered from neglect from the research community but contributions made to WHO by Nor- way in the past two years have radically changed this situation. Today there is optimism that an entirely new vaccine might be developed. Meanwhile WHO and other UN agencies are fostering intensive re- search on new vaccines to guard against malaria and other tropical diseases. And although no safe and satisfactory protective vaccines at present exist against diarrhoea} dis- eases, current work suggests that several may be available in the near future. WHO is giving priority to the development of vaccines against rotaviruses and entero-toxigenic Escherichia coli, which cause nearly half of the serious acute episodes of diarrhoea in children under the age of five. WHO is also focusing on vaccines against cholera, shigellosis (dysentery) and typhoid fever -diseases which have important epidemic potentials. Vaccines against these three latter infections have been in existence for some time, but are not considered to be useful public health tools. They suf- fer from low efficacy, short dur- ation of protection, impractical ad- ministration schedules, high reac- tion rates, or a combination of these drawbacks. • 23 Children-power in Mexico Photo-story by Liba Taylor [)] A recent National Vacci- nation Day in Mexico harnessed "children- power" to drive home the basic message that many young lives can be saved by systematic immunization in infancy. Schoolchildren marched through the streets of cities and towns carrying banners-some printed, some home-made- proclaim- ing" Polio maims for life," "Vaccinate me : help me" and "Vaccinate child- ren under five years of age." Health personnel at all levels took to the streets too, making house visits and using microphones and loud-hail- ers to ask parents of small children whether they had been protected. No doubt the children carried the same messages home to their pa- rents. There was an overwhelming response . Queues formed at health centres and out-patient departments as mothers, and fathers too, brought their babies forward for life-saving inocu lations and oral vaccines. Children-power can play a signifi- cant role in motivating adults and communities to take the crucial steps that will lead to better health . • 24 W ORLO HEALTH, Jan ./Feb. 1987 W oRLD HEALTH, Jan ./Feb. 1987 25 Smallpox showed the world the way by John F. Wickett Have you been vacci- nated? Have your children been vacci- nated? Value for money, it is probably the best health in- vestment you can make. It is a little misleading, perhaps, to class smallpox eradication as a successful "immunization pro- gramme," because today's immuni- zation programmes, to be successes, must be continuing and permanent features of the health system. Nevertheless, smallpox represented an unprecedented success as an eradication programme during the 13 years from 1967 to 1979 when the disease was totally eliminated. People surely welcomed the chance to avoid smallpox when Ed- ward Jenner, an Englishman, first demonstrated vaccination in 1796. He died a rich and honoured man. Smallpox was a horrifying disease, with no effective treatment once you got it and a more _than one-in- five chance of dying. In fact, people were so afraid of it that they prac- tised "inoculation," taking some matter from a pustule of a smallpox victim and placing it in a scratch on the arm of a healthy person in the hope of getting only a mild case; they knew that once you contracted the disease you were protected from getting it a second time. The chances of getting a full-blown case and dying were less ... but not neg- ligible. J enner discovered that "inocula t- ing" people with pus from an infec- tion on the teats of cows (cowpox) protected them from smallpox with no risk. To distinguish his method from "inoculation" he called it "vaccination", derived from the Latin word for cow. At the time people did not know why vaccin- ation worked, only that it did. Subsequent investigation of this 26 phenomenon led to the science of immunology that we know today. The French scientist Louis Pas- teur, paying hommage to Jenner's breakthrough in London in 1881, proposed that the word "vaccina- tion" be extended in meaning to cover all forms of active immuniz- Edward Jenner (1749-1823), disco- verer of smallpox vaccination and the father of immunology. He is shown here (at the rear, holding a paper) listening to an address by the founder of the Medical Society of London, John C. Lettsom. It was Lettsom who first sent samples of Jenner's new-found vaccine overseas to the United States. Contemporary drawing from the Medical Society of London. ation. Thus we now speak of polio vaccine, measles vaccine, and so on even though none of them has any- thing to do with a cow. Jenner's discovery of vaccination eventually resulted in the global eradication of smallpox-something he himself predicted at the time. But he might well have wondered why it took so long; 181 years elapsed between his discovery in 1796 and the occurrence of the world's last endemic case in 1977. On the other hand, mounting a worldwide vaccination programme was hardly a small undertaking. As recently as 1959, it was still believed that if each country simply staged vaccination campaigns reaching 80 per cent of the popula- tion, smallpox would be eliminated. In that year, WHO's World Health Assembly passed a resolution urg- ing countries to do just that. While the proportion of the world's popu- lation living in endemic areas de- creased from 59 per cent in 1959 to 30 per cent by 1967 and the number of countries with endemic smallpox fell from 59 to 31, this could hardly be considered effec- tive control, much less eradication. The approach to the problem needed serious revision. In 1966, WHO decided to actively promote and coordinate the eradication of smallpox, and it voted a specific budget allocation for staff and for material assistance to countries. The Intensified Smallpox Eradi- cation Programme started in 1967. Every disease has certain weak points susceptible. to attack. On the positive side in the combat against smallpox, freeze-dried vaccine was stable even in hot climates, gave long-lasting protection and was easy to administer. Moreover, the disease occurred only in humans. On the negative side, in 1967 a lot of vaccine being used was not up to required standards of potency and stability, and the health infrastruc- ture of many countries was insuf- ficient to mount a countrywide campaign. Furthermore, even 80 per cent vaccination coverage of the population could not elimi- nate smallpox in densely popu- lated areas. WoRLD HEALTH, Jan ./Feb. 1987 The essential ingredient was the intervention of an independent, in- ternational mechanism to coordi- nate matters. WHO organized the supply of vaccine through volun- tary donations, the support of na- tional vaccine producers and, most importantly, the establishment of international reference centres for A general vaccination day at the Paris Academy of Medicine in 1870. Vac- cination is being done directly from the cow. Engraving from the National Library of Medicine, Bethesda, USA. W oRLD HEALTH, Jan ./Feb. 1987 independent quality control of the vaccine. And it provided funds which helped countries to pay for vehicles, fuel and maintenance. Fundamental to the eradication of smallpox was the strategy used in areas with high population density. The virus which causes smallpox can only live in a human host, is not infective unless the victim has overt symptoms, and is transmitted rela- tively slowly from person to person by the respiratory route, like a cold. Thus in sparsely populated areas it tended to die out as it ran out of fresh victims. In densely populated areas it was not necessary to have a high overall vaccination coverage, but rather 100 per cent coverage in the immediate vicinity of a case. This was achieved by surveillance- containment, that is, quick recog- nition of a case, isolation of the case, and 100 per cent vaccination of everyone who could have had contact with the victim. It was this surveillance-containment strategy which finally resulted in eradi- cation, rather than a mass-vacci- nation campaign. If smallpox eradication can be thought of as an international effort of fixed duration, a worldwide im- An Ethiopian surveillance worker re- cording a case of smallpox in the early 1970s. As recently as 1967, smallpox was still endemic in 31 countries. The last case in the world occurred in neighbouring Somalia, in 1977. Photo W HO/P. Almasy munization programme must be thought of as a permanent system and infrastructure for regularly im- munizing children. Experience in the smallpox programme showed what a formidable task this could be. Nevertheless in 1973, only six years after the start of WHO's Inten- sified Smallpox Eradication Pro- gramme, the first meeting of the Committee for the WHO Expanded Programme on Immunization took place, and EPI was born. The total international invest- ment for smallpox eradication is estimated to have been no more than US $200 million, 1967-1979. The savings, in 1979 terms, from being able to stop routine vaccina- tion are estimated to be over $1000 million per year. If the returns on EPI are less easily calculated and not so immediately spectacular, they are enduring. Ask any child. • 27 28 Immunization milestones Louis Pasteur (1822-1895) showed how mankind can be protected against rabies. A contemporary por- trait and a drawing of his laboratory. 1721 Variolation (deliberate inocu- lation with smallpox virus), practised for centuries in Africa, China, India, and the Middle East, is introduced to Europe by Lady Mary Wortley Monta- gu, wife of the English ambassador in Turkey. In America, the Reverend Cot- ton Mather learns of variolation from his African slaves and introduces it in Boston. 1796 Edward Jenner, an English medical student, observes that milk- mai2s who have recovered from cow- pox are protected against smallpox. He practises his first inoculation on an 8-year-old boy on 14 May 1796 and announces his findings two years later. The word vaccination (from the Latin word for cow: vacca) replaces the term variolation. 1801 Dr Jenner's pamphlet on vacci- nation has been translated into five languages. More than 100,000 persons have been vaccinated in England. Jenner predicts the eventual "annihil- ation of the smallpox." 1870 Combatants in the Franco-Prus- sian war meet_ a common enemy: a smallpox epidemic. The French sustain 23,400 fatalities; the Germans lose only 278. The reason? The German army has been vaccinated. 1880 German scientist Robert Koch discovers the tubercle bacillus and begins work on a tuberculosis vaccine. 1885 Louis Pasteur of France intro- duces the rabies vaccine. Previously, a bite from a rabies-infected animal usu- ally resulted in "hydrophobia", which was inevitably fatal. By 1890, rabies vaccination centres exist in major cities throughout the world. 1890 The united efforts of bac- teriologists Emil A. von Behring of Germany and Shibasaburo Kitsato of Japan result in the discovery of toxin/antitoxin immunization for diph- theria and tetanus. They receive the Nobel Prize for their work in 1902. Robert Koch (1843- 1910) won the Nobel Prize for physiology and medicine in 1905 with his work on TB and other dis- Edward Jenner (1749-1823) disco- vered vaccination and became "the father of immunology." A doll dis- tracts a child from the brief scratch of the needle. Paul Ehrlich (1854-1915), another Nobel prizewinner, was a pioneer in diphtheria vaccines . . 1897 Paul Ehrlich evaluates the effec- tiveness of diphtheria antiserum in Germany and receives the Nobel Prize for further work in immunology in 1908. 1906 Albert Calmette and Camille Guerin of France produce an attenu- ated tuberculosis vaccine (bacillus Cal- mette-Guerin), now called the BCG vaccine. Following the discovery of the pertussis bacillus by the Belgian scientist Jules Bordet, several types of pertussis vac- cines are developed. His work earns him the Nobel Prize in 1919. 1940 After perfecting and testing a safer pertussis vaccine, American Pearl Kendrick begins trials of a combined diphtheria toxoid and pertussis vac- cine. 1954 Work by John Enders, Thomas Weller, and Thomas Peebles of Har- vard University (USA) leads the way to the development of a safe measles vaccine. American virologist and physician Jonas Salk produces the inactivated poliomyelitis vaccine (IPV) which is injectable. 1957 Albert Sabin of the United States brings out the live poliomyelitis vaccine. Taken orally, it is designated as OPV. . 1958 During the Eleventh World Health Assembly, the Soviet Union points out that the funds devoted to smallpox vaccination probably exceed the cost of wiping out the disease. WHA votes to step up efforts to eradi- cate smallpox. WoRLD HEALTH, Jan ./Feb. 1987 Ali Maow Maalin, the world's last victim of smallpox. Top: Front cover of World Health in May 1980. Below: A healthy and protected baby: the goal of EPI by 1990. 1963 Mass immunization campaigns using newly developed, safer measles vaccines begin in the United States and Europe. The United States reported 482,000 cases of measles in 1962; by 1968, the incidence had dropped to 22,000 c;ases. 1967 The World Health Organization (wHo) begins the campaign to eliminate smallpox from the planet. 1974 WHO's Expanded Programme on Immunization (EPI) is established. 1977 EPI sets its target: by 1990 to immunize all the world's children against the six childhood diseases :. measles, pertussis, diphtheria, tuber- culosis, poliomyelitis, and tetanus (in- cluding neonatal tetanus). 1977 Eradicated continent by conti- nent, smallpox makes its last stand in Somalia, East Africa. The last case, Ali Maow Maalin, makes a complete recovery. 1980 The .Thirty-third World Health Assembly officially declares smallpox completely eradicated from the planet. By now, safe and effective vaccines exist for about 20 infectious diseases. 1987 World Health Day (April 7) 1987 focuses on EPI, giving added impetus to immunization programmes worldwide in their attempts to reach the 1990 goal. 1990 Target date for EPI, when children worldwide will have access to immunizati.on services and will have the possibility of being fully protected against the six vaccine-P.re- ventable diseases. 29 ...... ....... ... ... ... ...... ...... ..... . .......... . ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••• ••o ••• ••••• ••••••• ••• ••• ••• ••••••• ... ... ....... ... ... ... ..... . . ......................... . ... ... ....... ... ... ... .... . . ......................... . ••• ••• ••• ••• ••• ••• • • ••• • ••••••••••••••• ••• ••• ••••••• ••••••••••• ••••• • ••• • •••••••••••••••••••• ••• ••• ••••••• ••••••••••• ••••• • ••• • ••••••••••••••••••• ••• ••• ••••••• •••••••••• ••••• ••• • •••••••••• ••••••• A catalogue for the cold chain An illustrated catalogue of the special equipment and gadgets that have been de- vised to support the "cold chain" is published by WHO and is regularly up-dated. As arti- cles elsewhere in this issue of World Health explain, the cold chain ensures that vaccines are kept cool and therefore potent all the way from the manufac- turing plant to the child . And unless this cold chain stays secure all the way, the vaccine risks having no effect. This can be unfortunate, and even fatal, for the vaccinated child or adult. But worse may follow. If a child is given measles vaccine that has been spoilt by exposure to direc;t sunlight or tropical heat, and subsequently catches measles, the entire community will lose confidence in the principle of immunization. Drop-out rates will rise, more children will miss their vital protection, and more will die. The sixth edition of the Cold Chain Product Information Sheets lists several categories of equipment. They include: cold rooms for bulk storage of Portable steam sterilisers for use in remote health centres. Photo WHO 30 vaccines, refrigerated vehicles, refrigerators and freezers, solar refrigerator systems, cold box- es, ice packs, thermometers and indicators, accessories, sy- ringes, and sterilisers. Infor- mation given includes a full description, the manufacturer, the dimensions and weight, the performance and energy requirements, additional com- ments, accessories, and prices. Some of the items listed are held as stock items by UNICEF and therefore are also identi- fied with a UN IPAC number, indi- cating that they can be order- ed from the UNICEF Packing and Assembly Centre in Free- port, 2100 Copenhagen East, Denmark. The product information sheets were originally issued jointly by . WHO and UNICEF in 1979, to convey technical and purchasing information on selected equipment for the storage, transport and ad- ministration of vaccines for the Expanded Programme on Im- munization (EPI) . The latest edi- tion has more than 150 pages and becomes the first of what will eventually be a technical series of publications issued by WHO/UNICEF on behalf of EPI. To obtain a copy of the latest edition, write to : Expanded Programme on Immunization, World Health Organization, 1211 Geneva 27, Switzerland. The sheets are published in English, French and Spanish. • A Thai Princess calls on WHO headquarters Princess Chulabhorn Valai- laksha of Thailand showed particular interest in the Ex- panded Programme on Im- munization when she paid a formal visit to WHO headquar- ters in Geneva last October. She talked animatedly on the subject to (left to right) Or Ralph H. Henderson, EPI Di- rector, Or Tore Godal, who di- rects the Special Programme for Research and Training in Tropical Diseases, and Or Half- dan Mahler, WHO's Director- General. During her visit, she said : "Thailand has been a staunch partner of WHO in trying to attain the goal of Health for all by the year 2000," And she added: "With a proper balance and A willingness to report AIDS? The first case of AIDS- the Acquired Immunodeficiency Syndrome- was described only six years ago. So the numbers of AIDS cases reported to WHO still give only a limited reflec- tion of the scope of the AIDS problem in the world . However, as Or Jonathan Mann, Respon- sible Officer for the wHo Con- trol Programme on AIDS, ex- plains: "Given the emotional and political climate which tends to characterise AIDS is- sues, we consider the reporting of even a fraction of known AIDS cases by national health judicious mix of science and technology for biomedical re- search and health service re- search in the context of cultur- al, traditional values and beliefs, Thailand will certainly reach its goal." Referring to Thailand as "a justly proud pioneer in primary health care," Or Mahler told the Princess: "We are delighted that Your Royal Highness has chosen to devote time to sup- port and assist Their Majesties (the King and Queen of Thai- land) in highly constructive ac- tivities aimed at better health, particularly in remote rural areas." Princess Chulabhorn Valai- laksha was also briefed on WHO's Special Programme of Research Development and Research Training in Human Reproduction, the WHO Pro- gramme on Traditional Medi- cine, and the International Pro- gramme on Chemical Safety. • authorities to be an expression of national willingness to deal constructively with the AIDS problem." WHO is encouraging its Member States to set up sur- veillance systems in order to improve the reporting and thus get a more accurate picture of the scope of the problem. The Control Programme on AIDS will in turn be responsible for coordinating, at the interna- tionallevel, the activities under- taken to combat AIDS and will work with countries to assist in the design and implementation of their national control pro- grammes. A total of 33,399 AIDS cases had been reported to WHO up to 28 October 1986. • WoRLD HEALTH, Jan./Feb. 1987 The health care of the future An International Conference on Future Health Care Technol- ogy w ill be held in Rotterdam, Netherlands, on 19 May 1987 to discuss policy implications of future technology, an early warning system, and health care technology assessment as an aid to policy-making. The eo-sponsors of the Con- ference are the Netherlands' Steering Committee for Future Health Scenarios (STG} and WHO's Regional Office for Europe. They w ill report on a two-year eva luation of the fu- ture role of genetic screening, new applications of the neuro- sciences, monoclonal anti- bodies and diagnostic kits, biotechnology and new vac- cines, and the use of lasers in cardiovascular su rgery. On 21 and 22 May, the Inter- national Society of Technology Assessment in Health Care w ill hold its third an nual meeting also in Rotterdam. Main themes on the agenda include quality of care and quality of life, and technology transfer. Founded in 1985, the Society encourages research, educa- tion, cooperation and the ex- change of information on the clinica l and socia l implications of health care technologies. lt also provides editoria l direct ion for the International Journal of Technology Assessment in Health Care, published by Cam- bridge University Press. For further details of either meeting, please contact: Health Council of the Nether- lands, P.O. Box 90517, 2509 LM The Hague, Netherlands . • High technology helps to de- tect brain tumours in Brazil. Photo WHO/PAHO W ORLD HEALTH, Jan ./Feb. 1987 Newsbriefs • New collaborating centre. Disabled people throughout East Asia and the Pacific will be able to benefit from the expertise and services of Hong Kong 's MacLehose M edical Rehabilitation Centre, which has now been designated a WHO Collaborating Centre for Rehabilitation. There are at least 100 million disabled people in the Western Pacific Region alone, 75 per cent of whom live without any outside help. The MacLehose Centre will help to promote community-based rehabilitation and will coordinate activities among coun tries in the region in the field of rehabilitation. • UN Volunteers. The United Nations Volunteers programme (uNv) marked its 15 years of service to development with a high-level inter-governmental meeting on "in ternational volunteerism and develop- ment. " Held in Maseru, capital of the southern African state of Lesotho, in November, the meeting reviewed the im- pact of volunteer service on the recipient countries, and identified ways to increase the usefulness of volunteer work as a cost-effective relevant tool for technical cooperation. UNV comprises some 1,200 2N0lJNVHIGHl(~ll oo;T[R()OV[ RNME HTAL M [["!ING MASERU, lESOTHO 16-21 November 1986 unv professionally qualified and experienced volunteers originating in 85 countries and serving in more than 90 developing countries. • Snakebite. A 27-minute video film called "Snakebite! " offers a chance for a wide audience to learn how to distinguish poisonous from non-poisonous snakes, and what firs t aid to give to victims. Already shown in India, Nigeria, and the United States, the film won the Best Professional award at an international wildlife film festiva l in Montana, USA. For purchase or rental prices, contact the makers of the film, Development through Self-Reliance, Inc., P. 0. Box 281, 9527 Good Lion Road, Columbia, Maryland 2,1045, USA. • Diagnosing leprosy. A new method of diagnosing leprosy should shortly be introduced into national leprosy control pro- grammes in WHO 's Western Pacific region. The new method uses a chemically synthesised antigen which enables simple and early detection of leprosy bacteria infection in the human body before any outward symptoms appear. Multi-drug therapy should then be even more effective in bringing the disease under control in the patient. According to Regional Director Or Hiroshi Nakajima, " with th is new diagnostic method and multi-drug therapy, together with recent progress in development of vaccines, the eradication of leprosy is no longer just a dream. " • Child labour. In some Asian countries today, child workers aged under 15 years represent as much as 11 per cent of the entire labour force, according to an International Labour Organis- ation (!LO) publication, Child Labour : a briefing manual. In parts of Africa the proportion is as high as 17 per cent, and available estimates from some Latin American coun tries indicate that between 12 and 26 per cent of the children may be at work. The worldwide army of working children numbers at least 100 million, and quite possibly nearly twice as many, the ILO study estimated. • Change of name. WHO 's Advisory Comm"ittee on Medical Research (ACMR) has been renamed the Advisory Committee on Health Research (ACHR). The Committee was originally established in 1959 "in order to provide the Director-General with the necessary scien tific advice in relation to the research pro- gramme. " Its members are top-level world scientists, including numerous Nobel Prize w inners. The change in name from ACMR to ACHR reflects a new approach which gives added emphasis to health protection and promotion without neglecting the importance of strictly medical research. In the next issue Many avoidable il lnesses are caused by improperly prepared or improperly stored foods. The .more people are made aware of simple prec;autions that must be taken, the fewer such illnesses there w ill be. Food manufacturers, the touri st industry, housewives and health personnel of all categories have a role to play in ensuring Food Safety- the theme of the March issue of World Health. Authors of tne Month Dr Halfdan MAHLER is Direc- tor-General of the World Health Organization. Dr Ralph H. HENDERSON is Di- rector of WHO's Expanded Pro- gramme on Immunization. Mr Donald ALLAN, formerly with UNICEF, is a freelance writer in Geneva. Mr James P. GRANT is Executiv:e Director of UNICEF, New York and Mr Jack LING, formerly Di- rector of WHO's Division of Pub- lic Information and Education for Health , is now visiting Professor of Communications at the University of Southwestern Louisiana, Lafayette, USA. Sir John WILSON is Senior Con- sultant for IMPACT (An Interna- tional Initiative . Against Avoid- able Disablement) , a Geneva- based organization promoted by the UNDP, UNICEF and WHO. Professor Leo A. KAPRIO is Chairman of the Global Advis- ory Group of the Expanded Pro- gramme on Immunization and Regional Director Emeritus of WHO's European Region . Major General Mohammad Ilyas BURNEY is Executive Director of the National Institute of Health , Islamabad, Pakistan , and Dr Faiyaz Ahmed LARI is also with the National Institute of Health. Mr Henry C. SMITH is EPI Tech- nical Officer with the Caribbean Epidemiology Centre ( CAREC), Pan American Health Organiz- ation, based in Trinidad. Mrs Lib a TA YLOR is a London- based photographer specialising in Third World affairs. Mr John F. WICKETT is a Con- sultant with WHO's Smallpox Eradication programme in Geneva. 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