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Geneva, Switzerland, WHO, 2009.  p.As part of efforts to obtain evidence to inform the public health approach to HIV treatment and prevention, the Population Council collaborated with the HIV / AIDS Department of the World Health Organization to develop tools, "HIV Testing, Treatment and Prevention: Generic Tools for Operational Research" for operational research on topics that have relevance to programs. The tools include this main document that is intended to serve as a basis for formulating research questions and designing an operational research project to address them. The document includes four sections: HIV testing and counseling; HIV stigma and discrimination; Adherence to antiretrovirals; and HIV prevention in the context of scaled-up access to HIV treatment.
Journal of Human Lactation. 2010 Aug; 26(3):297-303.The objective of this study was to translate and psychometrically assess a Portuguese version of the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). The original English version of the BSES-SF was translated to Portuguese and tested among a sample of 89 mothers in southern Brazil from the 2nd to 12th postpartum week followed by face-to-face interviews. The mean total score of the Portuguese version of the BSES-SF was 63.6 +/- 6.22. The reliability analysis of each item in the scale attained significant Cronbach's alphas of 0.63 or superior. The Cronbach's alpha generated by the entire range of 14 questions was 0.71. A factor analysis identified one factor that contributed to 20% of the variance. This study demonstrates that the original English version of the BSES-SF was successfully adapted to Portuguese. The Portuguese version of the BSES-SF constitutes a reliable research instrument for evaluating breastfeeding self-efficacy in Brazil.
European Journal of Contraception and Reproductive Health Care. 2008 Mar; 13(1):58-70.Acceptance of sexual and reproductive health as fundamental to the sustainable development of societies has allowed for creation of new reproductive health programmes and policies. WHO sexual and reproductive health (SRH) strategies were developed in the WHO Regional Office for Europe (2001), as well as globally (2004). Adolescent SRH is important in both strategies. Despite these commitments, adolescents remain vulnerable to poor reproductive health. The goal of this paper is to analyse the current status of SRH of adolescents in Europe. Key reproductive health indicators were chosen. Information was obtained from published studies, databases and questionnaires sent to WHO reproductive health counterparts within the health ministries in the Member States of the WHO European Region. Pregnancy rate, age at first sexual intercourse, contraceptive use at first and last intercourse, contraceptive prevalence, HIV knowledge, and STI rates vary widely according to the population considered. Gender difference and lack of information pertaining to SRH of all adolescent populations are other key findings. While the SRH of most European adolescents is good, they remain a vulnerable population. Lack of standardized reproductive indicators and age specific aggregate data make it difficult to accurately assess the situation in individual countries or perform cross country comparison. (author's)
Utility of the WHO ten questions screen for disability detection in a rural community -- the north Indian experience.
Journal of Tropical Pediatrics. 2007 Dec; 53(6):383-387.The utility of the WHO Ten Questions Screen (TQS) was studied in a rural community of North India. The study was done in three villages, in two phases. In phase 1, the TQS was administered to parents of children aged between 2 and 9 years, during a house-to-house survey. In phase 2, all children screened positive and a random sample of 110 screened negative were clinically evaluated in detail. The total population of the three villages was 5830 with 1763 children aged between 2 and 9 years. Seventy-six children were positive on the TQS, of these, 38 were found to have significant disability, 18 had protein energy malnutrition and 19 were found normal on clinical evaluation. All the 110 screen-negative children were normal. Significantly larger numbers of boys were positive on TQS as compared to girls [Odd Ratio (OR) 1.5]. The sensitivity of the TQS for significant disability was 100%; the positive predictive value was 50% and was higher for boys than for girls. Of the 50% children classified as false positive 23% had mild delays due to malnutrition. The estimated prevalence of disability was 16/1000. The TQS was found to be a sensitive tool for detection of significant disabilities among children 2-9 years of age. The low-positive predictive value would lead to over referrals but a large number of these children would benefit from medical attention. (author's)
Adolescents, social support and help-seeking behaviour: An international literature review and programme consultation with recommendations for action.
Geneva, Switzerland, World Health Organization [WHO], Department of Child and Adolescent Health and Development, 2007. 56 p. (WHO Discussion Papers on Adolescence)With this brief introduction and justification, this document presents: The findings from an international literature review on the topic of adolescents and help-seeking behaviour. The results of a programme consultation with 35 adolescent health programmes (including public health sector programmes, university-based adolescent health programmes and non-government organizations (NGO) working in adolescent health) from Latin America (10), the Western Pacific region (4), Asia (20), and the Middle East (1), and the results of six key informant interviews. These results are incorporated into the literature review where relevant. The complete report from this consultation of programmes is found in Appendix 1. Recommendations for action, including a brief outline for developing a set of guidelines for the rapid assessment of social supports to promote the help-seeking of adolescents. This document is part of a WHO project to identify and define evidence-based strategies for influencing adolescent help-seeking and identify research questions and activities to promote improved help-seeking behaviour by adolescents. To achieve this objective, the consultants, with WHO guidance: (1) carried out an international literature review of the topic; (2) sent 67 questionnaires and received 35 questionnaires back from adolescent health programmes on the topic of adolescents and help-seeking in the four regions; and (3) carried out key informant interviews with nine individuals (three in Latin America, three in the Pacific region and three in South Asia). The consultants also developed short case studies of illustrative approaches in promoting help-seeking behaviour. (excerpt)
Archives of Gynecology and Obstetrics. 2007 Dec; 276(6):583-589.The objective was to evaluate quality of life (QOL) and identify its associated factors in a cohort of women with gynecologic cancer. A cross-sectional study was conducted, including 103 women with cervical or endometrial cancer, aged between 18 and 75 years who were receiving their entire treatment at the institution where the investigation was carried out. QOL was measured by the World Health Organization's QOL instrument-abbreviated version (WHOQOL-BREF). Clinical and sociodemographic characteristics, in addition to prevalence of cancer-related symptoms prior to radiotherapy were investigated. Bivariate analysis was performed, applying the Mann-Whitney test. Multivariate analysis was used to identify factors associated with QOL. The mean age of the participants was 56.8 plus or minus 11.6 years. The study included 67 (65%) women with cervical cancer and 36 (35%) women with endometrial cancer. Most participants were at an advanced stage (63.1%). The most common complaints were pain (49.5%) and vaginal bleeding (36.9%). The prevalence of anemia was 22.3%. On multivariate analysis, it was observed that anemia (P = 0.006) and nausea and/or vomiting (P = 0.010) determined impairment in physical domain. Pain negatively influenced physical domain (P = 0.001), overall QOL (P = 0.024), and general health (P = 0.013), while the history of surgery positively affected general health (P = 0.001). Cancer-related symptoms were factors that most interfered with QOL in women with gynecologic cancer. Therefore, more attention should be focused on identifying these symptoms, adopting measures to minimize their repercussions on QOL. (author's)
Geneva, Switzerland, World Health Organization [WHO], 2006.  p.There is thus an increased awareness of the problem of child maltreatment and growing pressure on governments to take preventive action. At the same time, the paucity of evidence for the effectiveness of interventions raises concerns that scarce resources may be wasted through investment in well-intentioned but unsystematic prevention efforts whose effectiveness is unproven and which may never be proven. For this reason, the main aim of this guide is to provide technical advice for setting up policies and programmes for child maltreatment prevention and victim services that take into full account existing evidence on the effectiveness of interventions and that use the scientific principles of the public health approach. This will encourage the implementation of scientifically testable interventions and their evaluation. It is hoped that, in this way, the guide will contribute to a geographical expansion of the evidence base to include more evaluations of interventions from low-income and middle-income countries, and a greater variety of evaluated interventions. The long-term aim is to be able to prepare evidence-based guidelines on interventions for child maltreatment. (excerpt)
National adult antiretroviral therapy guidelines in resource-limited countries: concordance with 2003 WHO guidelines?
AIDS. 2006 Jul 13; 20(11):1497-1502.The aims were to investigate the existence of national adult antiretroviral therapy (ART) guidelines in 43 World Health Organization (WHO) '3 by 5' focus countries and compare their content with the 2003 WHO ART guidelines. Questionnaires covered initiation of ART, selection of first or second-line ART, monitoring treatment response and toxicity and dissemination of national guidelines. Weighted concordance scores were created and country scores correlated with national indicators and WHO recommendations. Thirty-nine (91%) countries returned questionnaires, three of which had no national ART guidelines. Of the 36, 16 (44%) recommended to start ART based on WHO clinical staging criteria and CD4 cell count or T-lymphocyte count, 12 (33%) WHO clinical staging criteria and CD4 cell count, four (11%) only CD4 cell counts. 35 (97%) recommended a standard first-line regimen and 24 (67%) preferred stavudine + lamivudine + nevirapine; 33 (92%) recommended second-line regimens, and 24 (60%) preferred abacavir + didanosine + lopinavir/ritonavir. Thirty-one (94%) recommended CD4 cell count, possibly combined with other indicators, to monitor ART. Concordance scores were higher in countries with lower health expenditure per capita (P = 0.009) and lower GDP per capita (P < 0.03). Median concordance scores for starting ART was 100 [interquartile range (IQR), 67 to 100]; first line therapy, 70 (IQR, 60 to 80); second-line regimens, 45 (IQR, 27 to 55) and for laboratory investigations, 80 (IQR, 80 to 100). Most countries had developed national ART guidelines as part of a comprehensive national HIV program. Concordance with WHO recommendations was strong on starting first-line ART regimens and routine monitoring but lower for second-line recommendations. (author's)
Journal of Family Planning and Reproductive Health Care. 2004; 30(4):253-254.The Clinical Effectiveness Unit (CEU) presents an illustrative response of a frequently asked question to the Members’ Enquiry Service on whether or not hormonal contraceptive use by women with a history of pregnancy-related cholestasis is safe or associated with recurrence of cholestasis. The Summaries of Product Characteristics (SPCs) for combined oral contraceptives (COCs) and progestogen-only pills (POPs) advise against use by women with a history of cholestatic jaundice or with severe pruritis in pregnancy. The World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use (WHOMEC), however, recommends that for women with pregnancy-related cholestasis the benefits of COC use outweigh the risks (WHO Category 2) and progestogen-only methods or non-hormonal methods can be used without restriction (WHO Category 1). No evidence was identified to support an increased risk of recurrence of symptoms with hormonal contraceptive use. The CEU advises that women with a history of pregnancy-related cholestasis should be informed about the unknown risk of recurrence with hormonal contraceptive use. After counselling regarding non-hormonal methods, women with a history of pregnancy-related cholestasis may choose to use hormonal methods (COCs, POPs, progestogen-only injectables, implant or intrauterine system). Women should be informed that the use of COCs and POPs in this situation is outside the product licence. (excerpt)
Working with adolescent boys: programme experiences. Consolidated findings from regional surveys in Africa, the Americas, Eastern Mediterranean, South-East Asia, and Western Pacific.
Geneva, Switzerland, WHO, Department of Child and Adolescent Health and Development, 2000.  p. (WHO/FCH/CAH/00.10)The survey and this report seek to contribute to the understanding of working with adolescent boys in health and health promotion. Pursuant to this purpose, the consultants contacted programmes working in health promotion with adolescent boys in four regions of the world. These contacts did not aspire to include all of the programmes which are working with adolescent boys in these regions, nor do they necessarily represent a random sample of those programmes. Where possible, the survey included a relatively small but representative number of organizations working with adolescent boys in other regions. The organizations were identified via colleague organizations, WHO regional and local offices, the literature review, personal contacts of the survey authors and via non-governmental organizations (NGOs) working in health/health promotion. As detailed below, the survey sought to gather information in a dozen specific areas of interest by means of a questionnaire, which was translated into Spanish and Arabic. Programme staff were requested to fill out the questionnaire and return it to the consultants. (excerpt)
Comparison of patient evaluations of health care quality in relation to WHO measures of achievement in 12 European countries.
Bulletin of the World Health Organization. 2004 Feb; 82(2):106-114.To gain insight into similarities and differences in patient evaluations of quality of primary care across 12 European countries and to correlate patient evaluations with WHO health system performance measures (for example, responsiveness) of these countries. Patient evaluations were derived from a series of Quote (QUality of care Through patients’ Eyes) instruments designed to measure the quality of primary care. Various research groups provided a total sample of 5133 patients from 12 countries: Belarus, Denmark, Finland, Greece, Ireland, Israel, Italy, the Netherlands, Norway, Portugal, United Kingdom, and Ukraine. Intra-class correlations of 10 Quote items were calculated to measure differences between countries. The world health report 2000 — Health systems: improving performance performance measures in the same countries were correlated with mean Quote scores. Intra–class correlation coefficients ranged from low to very high, which indicated little variation between countries in some respects (for example, primary care providers have a good understanding of patients’ problems in all countries) and large variation in other respects (for example, with respect to prescription of medication and communication between primary care providers). Most correlations between mean Quote scores per country and WHO performance measures were positive. The highest correlation (0.86) was between the primary care provider’s understanding of patients’ problems and responsiveness according to WHO. Patient evaluations of the quality of primary care showed large differences across countries and related positively to WHO’s performance measures of health care systems. (author's)
Indian Journal of Medical Sciences. 2002 Feb; 56(2):73-78.Tuberculosis remains a global problem inspite of the excellent drugs available to cure it. According to an estimate in 1995 there were 9 million cases of tuberculosis worldwide and 3 million deaths. Tuberculosis was declared a global emergency by WHO in 1990 as it had reemerged in countries where it was supposed to be on a decline. Global explosion of HIV infection coupled with chaotic treatment of tuberculosis, the world today is threatened with untreatable epidemic of tuberculosis. Inappropriate and inadequate treatment leads to acquired drug resistance, which may result in treatment failure and spread of resistant organisms to other persons. The only way to prevent this is uniformity in the treatment of such patients both in governmental programs and private practice. In India under national tuberculosis control program 1.5 million cases are detected every year but still 1200 cases die due to it daily. The reason for this could be lack of compliance by the patients, faulty drug distribution, emergence of MDR-TB and inappropriate prescriptions of anti TB drugs due to lack of knowledge regarding the guidelines. Our study was aimed at finding out the knowledge, attitude and practice of resident doctors and consultants treating tuberculosis in two medical institutes in two different states of India. (author's)
Nutritional status of vegetarian and omnivorous adolescent girls. [Estado nutricional de adolescentes vegetarianas y omnívoras]
Nutrition Research. 2001 May; 21(5):689-702.This study compared the dietary and anthropometric profile of 24 ovo-lacto-vegetarian and 36 omnivorous female adolescents, between 15 and 18 years old. Weight, height and skinfolds were measured. Food frequency questionnaires and a three day food record were used for dietary assessment. Vegetarians presented subscapular, suprailiac and midaxillary skinfolds statistically higher than omnivores, but the percent body fat was not different. The vegetarian diet provided smaller amounts of energy than that of the omnivores ( p < 0.05) and only 17% of the vegetarians was able to reach the recommended allowance for protein. Regarding calcium, 83% of the vegetarians and 69% of the omnivores ate less than 2/3 of the recommended allowances and a significantly higher percentage of vegetarians presented low ingestion of iron, riboflavin, and niacin than omnivores ( p < 0.05). It was concluded that the intake of vegetarians was lower in fat and cholesterol, and less adequate in micronutrients than the omnivores ones. (author's)
Indicators for assessing health facility practices that affect breastfeeding. Report of the Joint WHO / UNICEF Informal Interagency Meeting, 9-10 June 1992, WHO, Geneva.
Geneva, Switzerland, WHO, 1993. , 32 p. (WHO/CDR/93.1; UNICEF/SM/93.1)In March and June 1992, WHO and UNICEF held a joint informal interagency meeting on breast feeding at WHO headquarters in Geneva. The goal of the meeting was to reach consensus on the definitions of key breast feeding indicators which would allow one to assess whether health care facilities' procedures support, protect, and promote breast feeding practices. Section 2 of the meeting's summary report covers these indicators and their potential users. Identified potential users are maternity services, postnatal outpatient clinics including maternal and child health care services, pediatric inpatient services, and family planning services. Section 3 provides precise definitions of the indicators and the rational for their selection. Representatives from participating activities were asked to propose data collection methodologies to measure these indicators. The participating agencies included UNICEF, the WHO Working Group on Infant Feeding, The Population Council, World Alliance for Breastfeeding Action, Wellstart, the Institute for Reproductive Health at Georgetown University, USAID, the Swedish International Development Agency, and WHO. They agreed on health facility-based indicators of breast feeding. Section 4 discusses mainly indicators based on interviews with mothers at the time of infants' discharge or at the time of attending a clinic. It briefly covers those based on information collected from health facility staff or observation at the facility. The interviews with mothers were the basis for all the indicators agreed upon at the meeting, except for maternity services indicator 2 (breast milk substitutes and supplies receipt rate). Section 5 addresses methodological issues to be developed and sampling considerations. The annexes include a list of participants in the March and June meetings, sample data collection instruments (i.e., questionnaires), and breast feeding indicators for health facilities.
Interview schedule for Knowledge, Attitudes, Beliefs and Practices on AIDS. Phase I: African countries. A. Household form. B. Community characteristics. C. Individual questionnaire.
[Unpublished] 1989 Feb. 28 p.The household interview form has spaces in which to designate a household's location and track interviewer visits with notation of visit results. Basic information can be recorded about the people over age 10 years who usually live in the household or who slept in the household on the preceding night. Data are then taken on the community characteristics form on the type of locality, travel time to the nearest large town, and facilities available in the community. The individual questionnaire is for people aged 15-64 years who slept in the household on the preceding night and is comprised of the following sections: identification; individual characteristics; awareness of AIDS; knowledge on AIDS; sources of information; beliefs, attitudes, and behavior; knowledge of and attitudes toward condoms; sexual practices; injection practices; locus of control; IV drug use; and drinking habits.
CONTRACEPTION. 1993 Apr; 47(4):359-66.To determine whether the known adverse effects of IUD use were kept to a minimum, 432 doctors were asked to complete questionnaires about their training and practice in IUD insertion, providing information about the insertion and the patient during a 3-month period. 349 doctors returned the first questionnaire. 93% of doctors had received some formal training in IUD insertion, although 54% had performed fewer than 5 supervised insertions before carrying out an unsupervised insertion. Only 8% had performed 10 or more supervised insertions. 58% had performed only 1 or no insertions in the month before the study period. 91% of respondents carried out more than 1 pelvic examination per week. Only 12% of doctors reported always prescribing prophylactic antibiotics. More doctors routinely took vaginal and cervical swabs for culture and cervical smears. 66% of doctors routinely arranged follow-up appointments. 98% of doctors routinely gave some information to women after IUD insertion. 90% of doctors provided a description of symptoms of infection. Information about women using an IUD was obtained from 129 doctors in 460 completed questionnaires about IUD insertions. Relative contraindications to IUD use included nulliparity, a history of suspected or proven pelvic inflammatory disease (PID), a significant risk of sexually transmitted disease (STD), and uncompleted family. Excluding uncompleted family, there were 126 insertions (27%) with at least 1 relative contraindication. Gynecologists performed 30% of the insertions in cases with relative contraindications compared with 48% for other doctors. 35 women who had IUDs inserted were nulliparous, and 4 of these were aged under 20, 11 women (2%) had an IUD inserted despite a history of suspected or proved PID. 12% of the women with IUDs were not in a stable sexual relationship; 9% had a history of STD, and 28% intended to have children in the future. 5% had both a risk factor for PID and an uncompleted family.
[Unpublished] 1992. Presented at the 8th International Conference on AIDS / 3rd STD World Congress, Amsterdam, Netherlands, July 19-24, 1992.  p.Three questionnaires which ask questions about prostitutes' sexual contacts with clients, short-term casual partners, and long-term partners were compared to determine whether the most detailed of the 3 would obtain data on unsafe sex practices otherwise overlooked by the other 2 versions. A World Health Organization (WHO) questionnaire, a revised version of the WHO questionnaire developed for a Toronto-based study involving IV-drug users, and a 3rd specifically targeting prostitutes were employed. Unsafe sex practices, albeit some considered high-risk and others low-risk, include: anal and/or vaginal intercourse with or without a condom, fellatio without a condom, cunnilingus without a barrier during menses, and the sharing of sex toys. Toronto prostitutes pre-tested the most detailed of the 3 questionnaires. Results indicate that all unsafe sex activities with clients would be reported equally well by each of the questionnaires. The 2 less detailed questionnaires would, however, miss a number of unsafe sex practices between prostitutes and lovers reported in the most detailed questionnaire. Missing data would not be obtained even if both of the less-detailed versions were used. This study highlights the need to develop and use questionnaires which assess all data on unsafe sex behavior which are relevant to the formulation and implementation of effective HIV prevention programs.
HEALTH POLICY AND PLANNING. 1992 Sep; 7(3):251-9.Policymakers and program managers rely on the oral rehydration solution (ORS) use rate as an indicator of program performance. The ORS use rate has several limitations, e.g., it disregards other program objectives. Other diarrheal disease control program objectives may include reducing the source of infection, promotion of effective home-based treatment, and training of health workers in appropriate diarrhea case management. WHO and the Demographic and Health Surveys (DHS) try to standardize the methodology for estimating ORS use rates, but they have not looked at them as cross-country indicators. Error sources lie in the terms used for diarrhea, the reference period, and the sequence of questions referring to treatment. In Bangladesh, the people recognize different types of diarrhea and treat each type differently. In 1 instance, health workers informed mothers to prepare and give a homemade sugar salt solution. Later they learned that mothers did not use ORS very much because they only used ORS for the type of diarrhea the health workers described. There has been considerable variation of ORS use rates in Bangladesh, perhaps because of the differences in meanings of the words used for diarrhea. The DHS uses a 2-week reference period, yet a Bangladesh survey finds underreporting of diarrheal episodes which occur early in the week of the survey. Other surveys do not use a specific reference period and mothers tend to remember only serious diarrheal episodes. A direct question about ORS use in surveys is too leading as indicated by higher ORS use rates when interviewers prompt respondents. ORS use rates do not give a true picture of a program and can even be counterproductive. No consensus exists as to what is high ORS use rate and what is low ORS use rate. Managers should not use ORS use rates as the only program indicator.
[Unpublished] 1989 Feb. 3,  p.The Siriraj Family Planning (FP) Research Center in Bangkok, Thailand has developed a protocol to conduct acceptability studies of the female condom Femshield. The study aims to assess participants' attitudes towards this new contraceptive which also protects against sexually transmitted diseases (STDs). Since barrier method use (condom and vaginal spermicide) is low in Thailand, the center has introduced the WHO supplied Femshield to increase protection against sexually transmitted diseases (STDs). 3 advantages of Femshield are it allows free movement of the penis; can be inserted before intercourse; and protects the perineum (where lesions may exist), urethra (an entrance of infection), and the roots of the penis. The Femshield is made of a polyurethane sac (dimensions 8 cm x 15.5 cm; .045 mm thickness) with a removable internal ring to help in insertion and an external ring to hold it in place. The study should include 10-15 sexually active women from each FP clinic who currently use a contraceptive method, are either married or living with a male partner, are willing to participate, and whose willing partners will complete a questionnaire after use. 1st FP personnel will use a screening form to ask each current user of any FP method her attitude based on her perception of Femshield and to participate in the study. Once she decides to participate, she formally consents. A FP worker then uses an admission form to interview her. She next receives 5 Femshields, verbal instruction on how to use them, and a small instructional manual. A FP worker interviews her during the 1 month follow up (follow up form). Study workers send a questionnaire to the partner (husband's form) with instructions to complete the form and return it to the FP clinic. Researchers use the 4 completed forms to analyze the data. (The protocol includes copies of all the standardized forms.)
[Unpublished] 1988. , 39 p. (GPA/HPR/88.1)Acquired immunodeficiency syndrome (AIDS) health promotion involves the use of information and education to change the behaviors of individuals and groups in ways that will control the spread of the virus. Effective promotional activities can make AIDS prevention a high public health priority, promote social support for positive behavioral changes, establish public support for the community and institutional responses required to control the transmission of AIDS, and support the training of workers in the health care field. Through its reliance on multiple communication channels and cooperation with the health and social service sectors, health promotion seeks to achieve sustained change in practices crucial to public health. The key to effective health promotion is adequate planning, services, and the supplies. This guide is aimed at providing planners, manages, and technical staff with a frame of reference for planning, implementing, implementing, monitoring, and evaluating AIDS health promotion programs. Discussed in detail are the following elements of program planning: establishing goals, initial assessment, targeting audiences, setting objectives and targets, developing messages and materials, developing communication strategies, providing support services, monitoring and evaluation, scheduling and budget, and reassessing the program. Dispersed throughout are examples of promotional materials and strategies.
[Unpublished] 1987 Apr 30. , 53 p.Neonatal tetanus, caused by the toxin of Clostridium tetani, is transmitted via unclean instruments used to cut the umbilical cord or contaminated dressings applied to the stump. The symptoms are inability to suck, trismus, convulsions, and (in 80-90% of cases) death on the 7th or 8th day. In the US between 1982 and 1984 only 2 cases of neonatal tetanus were reported; in the developing world an estimated 800,000 infants die of neonatal tetanus every year. The survey methodology used to determine the neonatal tetanus death rate was a 2-stage sampling method, known as the Expanded Program on Immunization 30 cluster sampling method, followed by questionnaires. Such surveys contain a certain amount of built-in bias due both to fact that the final selection of households is never completely random and that retrospectively gathered information is subject to recall bias. The surveys indicated that neonatal tetanus incidence was highest in rural areas, especially where animals were present; in the slums of cities; among families with many children; where mothers received no prenatal care; and where birth attendants were untrained. The best preventive strategy against neonatal tetanus is provided through immunization of the mother with tetanus toxoid, since the antibodies cross the placenta and protect the infant through the neonatal period. Unfortunately, the tetanus vaccination program lags at least 30% behind other World Health Organization Expanded Program on Immunization coverage. The World Health Organization recommends an initial immunization with .01 antitoxin International Units per milliliter of serum, a 2nd dose 4 weeks later (at least 2 weeks before delivery) and booster doses on each successive pregnancy up to 5; the 5th booster provides lifetime protection. Immunization should also be carried out among nonpregnant women of childbearing age and children. The World Health Organization has proposed that neonatal tetanus be made a reportable disease, which should be combatted by prenatal immunization of mothers and training of traditional birth attendants. Between 60% and 80% of all births in developing countries are attended by traditional birth attendants, but, except in China, the training of traditional birth attendants has not contributed as much to reduction of neonatal tetanus as has immunization. Alternative strategies for carrying out tetanus immunization programs include integrating them into prenatal clinics, schools, family planning programs, maternal food distribution programs, well-baby care centers, mass campaigns (especially in urban areas), and mobile team outreach strategies in rural areas. Tetanus immunization could also be linked to other Expanded Program on Immunization programs even though these are mainly targeted at children rather than mothers and other women of childbearing age. Indonesia initiated a tetanus immunization program in 1977 and a traditional birth attendant training program with assistance from the UN Childrens Fund in 1978. However, 3 neonatal tetanus surveys, conducted in 19 provinces, the city of Jakarta, and Java, estimated the total number of deaths/year from neonatal tetanus as 71,150--a neonatal tetanus mortality rate of 11/1000. 3 provincial level studies, also using the Expanded Program on Immunization 30 cluster sampling method, in Nusa Tenggara Barat, West Sumatra Province, and Daerah Istemewah Aceh revealed neonatal tetanus mortality rates of 8.3/1000, 18.5/1000, and 8.4/1000 respectively. In the Health portion of Indonesia's 4th 5-year plan (Pelita IV), the 1st priority is given to reducing the neonatal death rate of 93/1000 live births; the 7th priority is reduction of mortality due to neonatal tetanus by ensuring adequate immunization as part of routine health services and by requiring 2 tetanus immunizations of all women applying for a marriage certificate.