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  1. 1

    Diarrhoeal and acute respiratory disease: the current situation.

    World Health Organization [WHO]. Office of Information

    IN POINT OF FACT 1991 Jun; (76):1-3.

    This paper describes the serious effect of diarrheal and acute respiratory (ARI) disease upon children under 5 years old, and international efforts undertaken by the World Health Organization (WHO) to reduce such mortality. Combined, these diseases account for more then 1/2 of all deaths in this age group, and constitute the most serious threat to their health. WHO estimates for 1990 that diarrheal illnesses caused 3.2 million childhood deaths and that ARI caused 4.3 million. While some child deaths are due to measles and pertussis, the majority is caused by pneumonia and the consequences of diarrheal illnesses. These deaths could be readily averted through the timely, effective treatment of trained health workers with essential drugs. Immunization as well as improved nutrition, particularly through the practice of exclusive breast feeding of the child's 1st 4-6 months of life, are addition weapons potentially employed against child mortality. WHO programs for diarrhea and ARI control focus upon simplified treatment guidelines, training, communication messages, drug supplies, and evaluation methodology. Despite obstacles such as the marketing of useless and/or potentially dangerous anti-diarrheal drugs and cough and cold remedies, and inappropriate breastmilk substitutes and unnecessary foods, widespread progress in program development and implementation has been made over the past decade. Increased amounts of oral rehydration therapy and solutions are available and used, while many health workers have benefited from training programs.
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  2. 2

    [The control of viral diseases in the developing countries with the use of existing vaccines] Borba s virusnymi bolezniami v razvivaiushchikhsia stranakh s pomoshchiu sushchestvuiushchikh vaktsin.

    Gendon I


    In developing countries, every year about 70 million measles cases occur with 1.5 million deaths, over 200,000 children contract paralytic poliomyelitis, 50 million people get infected with viral B hepatitis causing over 1 million deaths, and several thousand people perish because of yellow fever according to WHO data. At the present time, there are 12 vaccines against viruses: vaccines against German measles and mumps in addition to the above. The universal immunization program (UIP) of WHO targets measles and polio. In 1989, a WHO resolution envisioned a 90% immunization coverage by the year 2000. Measles vaccination is recommended for children aged 9-23 months, since most children have maternal antibodies during the first 3-13 months of age. The Edmonston-Zagreb vaccine provided seroconversion of 92, 96, and 98% for 18 months vs. the 66, 76, and 91% rate of the Schwarz vaccine. In the US, measles incidence increased from 1497 cases in 1983 to 6382 cases in 1988 to over 14,000 cases in 1989, prompting second vaccination in children of school age. The highest incidence of polio was registered in Southeast Asia, although it declined from 1 case/100,000 population in 1975 to .5/100,000 in 1988. Oral poliomyelitis vaccine (OPV) provides protection: there is only 1 case/2.5 million vaccinations. Hepatitis B has infected over 2 billion people. About 300 million are carriers, with a prevalence of 20% in African, Asian, and Pacific region populations. Plasmatic and bioengineered recombinant vaccine type have been used in 30 million people. The first dose is given postnatally, the second at 1-2 months of age, and the 3rd at 1 year of age. Yellow fever vaccine was 50 years old in 1988, yet during 1986-1988 there were 5395 cases with 3172 deaths in Africa and South America. Vaccination provides 90-95% seroconversion, and periodic follow-up vaccinations under UIP could eradicate these infections and their etiologic agents.
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  3. 3

    Universal child immunization: goal attained.

    WORLD HEALTH FORUM. 1991; 12(4):493.

    The achievement of immunizing 80% of the world's children against 6 diseases was officially reported to the UN in New York on 8 October 1991 by WHO's Director-General, Dr. Hiroshi Nakajima, and UNICEF's Executive Director, Mr. James P. Grant. The lives of more than 3 million children are now saved each year through immunization against 6 preventable childhood diseases (poliomyelitis, measles, diphtheria, pertussis, tetanus, and tuberculosis). This celebration is proof of how much good can be done for children--for humankind--when the twin engines of political will and popular participation work together with advances in medicine and technology, said the UN Secretary-General, Mr. Javier Perez de Cuellar. Both Dr. Nakajima and Mr. Grant spoke of the massive mobilization at all levels of society that had gone into achieving the global target of 80% child immunization by the end of 1990, which was established by the World Health Assembly. "This tremendous achievement--resulting from the most massive international peacetime collaboration in history--is now preventing the deaths of some 3 million young children each year, and enabling many millions more to grow in better health and without disabilities, they said in their official certification statement. Dr. Nakajima noted the need to harness biotechnology to improve existing vaccines, so that they can be given earlier in life, with fewer doses, and without the need for a complex cold chain to preserve their potency. And above all, the new, improved vaccines should be made affordable. Mr. Grant described the achievement as "a world war worth fighting," using vaccines instead of bullets, where children had quietly emerged victorious. He stressed the need to press ahead with new goals--90% immunization coverage, the elimination of neonatal tetanus, the dramatic reduction of measles, and the eradication of poliomyelitis within this decade. (full text)
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  4. 4

    Missed opportunities for immunization: the REACH experience.

    Grabowsky M

    Rosslyn, Virginia, John Snow [JSI], Resources for Child Health [REACH], 1991 Mar. [5], 16 p. (USAID Contract No. DPE-5927-C-00-5068-00)

    Children may fail to come into contact with the immunization system, may drop out before becoming fully immunized, or may stay in the system long enough to gain full immunity from given target diseases. As child immunization coverage nears 80% at the end of 1990, greater emphasis will be placed upon the quality of Expanded Program on Immunization (EPI) services. It is important to lower barriers to immunization and increase the certainty that every immunized child gains full protection. While EPI managers are able to measure coverage levels and assess and monitor immunization quality with the EPI 30-cluster survey, the analysis is complex and time-consuming. The Coverage Survey Analysis System (COSAS), however, employs computer technology to quickly and accurately analyze data. COSAS was developed by the World Health Organization with the input of assisting organizations and gives program managers access to information on the age distribution of immunizations, dose intervals, dropout rates, and other factors which influence program quality. Missed opportunities for immunization (MOI) occur when a child eligible for immunization leaves a health center without obtaining antigens needed for full protection. MOIs are therefore sensitive indicators of the quality of EPI services. Exit interviews have observed MOIs in certain developing countries in the range of 17-76% with a median of 49%. This decreased likelihood of a child being immunized infers eventual higher costs, delayed or missed protection, and loss of confidence in the EPI system. COSAS may help evaluate the quality of care, but it is unable to identify the determinants of quality care. Observation checklists and exit interviews are, however, able to determine the causes of poor service quality and find that they are frequently due to false contraindications, improper screening, lack of supplies, fear of giving multiple injections, and poor clinic organization.
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  5. 5

    The state of the world's children 1991.

    Grant JP

    Oxford, England, Oxford University Press, 1991. [8], 128 p.

    The State of the World's Children for 1991 begins with a promise by world leaders to adopt an ambitious series of goals for 2000 with an objective to end child death and child malnutrition at today's levels. Keeping the promise will not be easy since raising the resources to meet this goal will mean giving children a new, higher priority. Success will only be achieved by following certain principles, for example, reaching the immunization goals for the year 2000 will require almost every organization and person in both developing and developed countries to work hard. In order to succeed in only 10 years, a new ethic must develop which gives children a number 1 priority even in bad times. Reducing child deaths by 33% during this decade will mean essential steps must be taken in the process of reducing births and slowing population growth. The current generation will be charged with caring for the largest generation of children ever. Their performance will ultimately be judged according to the outcome of the children of the 1990s.
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  6. 6

    The approach of monitoring and surveillance in EPI.

    Abeyesundere AN

    IN TOUCH 1991 Jun; 10(99):18-20.

    The Bangladesh collaborative effort with WHO in strengthening monitoring procedures, developing disease surveillance, and evaluating periodically for the Expanded Program on Immunization (EPI) is discussed. Field data are gathered in periodic reviews and there are routine supervisory visits. The supervisory network i strengthened by the supervision of the consultation with local WHO Divisional Operational Officers. A routine reporting system provides data on immunization coverage by age and dose and number of vaccinations. Each form has 1) the annual targets for eligible women and children, 2) the cumulative vaccinations for the year, and 3) % of the target reached. Wall charts in the Upazila Health Complex and district health office also provide these data. 36 samples surveys have been conducted by local officers trained by WHO experts. 210 children are studied in clusters of 30 to provide 95% accuracy within 10 points of the true value. The vaccination reports are thus validated, and additional information provided on the number of fully immunized children dropout rates, reasons for partial immunization, and source of immunization. Disease surveillance is weak. Annual workshops have been held in 1986-90 to advance correct diagnoses and provide sentinel site data. 15 sentinel hospitals how provide admission data on diphtheria, tetanus, and poliomyelitis cases. Field-based epidemiological teams are being created. These steps are necessary to reach disease prevention goals. Special surveys have been conducted periodically to estimate the magnitude of the problem. In 1983, a lameness survey was conducted. The findings were that 61.3% of the poliomyelitis children became lame at <3 years, and 33% of lameness among 0-4 year olds was caused by poliomyelitis in 1983. A measles survey in 1985 in urban areas found an incidence of 2.6 million <5 years and 45,000 deaths annually. Case fatality was 1.74%. Diarrhea occurred in 38-75.5% of the measles cases; pneumonia in 2.2-11.7%. In 1986 in rural areas, neonatal tetanus had a mortality rate of 41/1000 live births, and 50% of neonatal deaths. In 1989 there was a reduction to 7-12/1000 live births. A computerized EPI information system (CEIS) is in place with computers and equipment at headquarters and in all 4 divisions. Monthly analysis is made at the national level. Current review has revealed high vaccination coverage. The focus for the future must be changed from vaccination coverage (at a cost for 1989-90 of Taka 202 or US$5.79 to disease reduction.
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  7. 7

    International assistance and health sector development in Nigeria.

    Parker DA

    Ann Arbor, Michigan, University Microfilms International, 1991. vii, 266 p. (Order No. 9116069)

    The effectiveness of official development assistance in responding to health problems in recipient countries may be examined in terms of 1) the results of specific aid-supported projects, 2) the degree to which the activities have contributed to recipients' institutional capacity, and 3) the impact of aid on national policy and the broader development process. A review of the literature indicates a number of conceptual and practical constraints to assessing health aid effectiveness. Numerous health projects have been evaluated and issues of sustainability have been studied, but relatively little is known about the systemic effects of health aid. The experience of Nigeria is analyzed between the mid-1970s and the late 1980s. In the 1970s, Nigeria's income rose substantially from oil revenues, and a national program was undertaken to increase the provision of basic health services. The program did not achieve its immediate objectives, and health sector problems were exacerbated by the decline of national income during the 1980s. Since 1987, a progressive national primary healthcare policy has been in place. Aid has been given to Nigeria in comparatively small amounts per capita. Among the major donors, WHO, UNICEF, and, most recently, the World Bank, have assisted the development of general health services, while USAID, UNFPA, and the Ford Foundation have aided the health sector with the principal objective of promoting family planning. 3 projects are examined as case studies. They are: a model of family health clinics for maternal and child care; a largescale research project for health and family planning services; and a national immunization program. The effectiveness of each was constrained initially by limited coordination among donors and by the lack of a supportive policy framework. The 1st 2 of these projects developed service delivery models that have been reflected in the national health strategy. The immunization program has reached nationwide coverage, although with uncertain systemic impact. Overall, aid is seen as having made a marginal but significant contribution to health development in Nigeria,a primarily through the demonstration of new service delivery approaches and the improvement of management capacity. (author's)
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  8. 8
    Peer Reviewed

    Poliomyelitis: what are the prospects for eradication and rehabilitation?

    Jamison DT; Torres AM; Chen LC; Melnick JL

    HEALTH POLICY AND PLANNING. 1991 Jun; 6(2):107-18.

    The WHO estimates that 74% of the world's children were fully immunized against poliomyelitis by early 1990. Despite this, the disease is still paralyzing almost 1/4 of a million individuals each year and killing perhaps 25,000. This paper, 1 of a series undertaken on specific diseases for the World Bank's Health Sector Priorities Review on disease of major importance in the developing world, reviews available evidence on the cost effectiveness of polio prevention. This prevention would take the form of either immunization or case management of polio to minimize and rehabilitate disabilities. The power of available vaccines and the characteristics of disease suggest the technical feasibility of eradication of disease from polio (but not the polio virus) as a goal for the year 2000. With sustained national and international support, it is thus reasonable to hope for eradication by that year or soon thereafter. Rehabilitation of those disabled by polio (and other causes) has been neglected both by governments and by the international community. Although hard evidence on cost and effectiveness remains to be gathered, what is know strongly suggests that effective rehabilitation programs could be implemented at low cost and with the economic and welfare benefits far exceeding the expenditures. (author's modified)
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  9. 9

    Bangladesh national immunization cluster survey: 1991.

    De Silva R; Herm H; Khan M; Chowdhury JH

    In: Near miracle in Bangladesh, edited by Mujibul Huq. Dhaka, Bangladesh, University Press Limited, 1991. 85-96.

    The WHO standard national immunization coverage evaluation survey of Bangladesh, which was independent of EPI reporting or the Ministry of Health service delivery system, is presented. Included are observations from the field. Multistage sampling techniques were used to identify at the divisional and national level 30 clusters from 11,000 villages and 30 from the 5 metropolitan areas. 7 children ages 12-17 months who were born between August 1989 and January 1990 were selected from each cluster. The immunization record was used where possible. Enumerators were selected from each cluster. The immunization record was used where possible. Enumerators were selected form outside the government immunization or health worker population. The results of the histograms indicate high levels of coverage of region Rajshahi and low coverage for Chittagong, a pattern typical of contraceptive prevalence, Vitamin A distribution, and literacy. Bar graphs distinguish between the fully immunized child (3 doses of DPT and OPV, 1 dose of BCG, and 1 dose of measles) at <1 year and 12-17 months, based solely on immunization record data. Dropout rates are compared between those receiving BCG and the measles vaccination. The high dropout rate means greater effort in order to maintain 80% coverage. The bar chart on reasons for not continuing immunization shows time/place unknown and unaware of the immediate need were the 2 most reported reasons at 12.2% and 11.9%. Motivation was not a reason. It is suggested that health workers did not sufficiently stress the importance of continuing vaccination. The WHO reported coverage figures did not correspond to regular reports, which overestimated; the estimated number of births may be too low, or WHO figures did not include the mop-up program begun in the last quarter of 1990, or those receiving the 3rd dose even if older than 12 months. The urban reports were lower than the WHO reports perhaps because of reporting error between hospitals and private physicians and NGOs. Reported figures for DPT/OPV3 were significantly higher than WHO figures and assumptions cannot be made that coverage is high enough to offer disease protection and mortality reduction. TT coverage was 74%, but again there was a problem obtaining records. There was a lack of antenatal care. Recommendations were, for instance, that HAs, TBAs, and FPAs emphasize the importance of follow-up coverage and antenatal care, and that the Chittagong area receive more attention. The integration of immunization with family planning and the considerable coverage in such a short time are accomplishments to be proud of.
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  10. 10

    Cost effectiveness and sustainability of immunization.

    Noto A; Mahmood RA; O'Brien P; Kawnine N

    In: Near miracle in Bangladesh, edited by Mujibul Huq. Dhaka, Bangladesh, University Press Limited, 1991. 75-84.

    Sustainability of EPI in Bangladesh is based on capital, recurring costs, and unit costs. These costs, sources of financing, the capacity of the domestic economy to finance the cost of maintaining the program, and nonfinancial aspects of sustaining EPI are discussed. The capital costs for construction of buildings, machinery and equipment, and skill development and training has been reduced in 1988-89 to 9.15% of the budget. Recurring costs, which will increase as coverage increases, constitute 90.85% and pay for wages, fuel, rents, and vaccines. The unit cost is low at 5.79/child compared with the world average of 13. WHO's standard formula of dividing total annual EPI costs by children immunized for measles times 90% is used. However, this figure assumes full immunization, which is estimated at an additional cost of 4.21/child. Over the long term, costs will come down. Now funding comes from the government, multilateral UN agencies (UNICEF at 57% including other sources and WHO), international NGOs, and bilateral donors [USAID, SIDA, Swiss Development Corporation (SDC), and Canadian International Development Agency (CIDA)]. Government funding covers salaries, transport, fuel, travel allowances, and TT vaccines. Contributions from UNICEF provide capital expenses, training stipends, and communication materials. USAID channels money through an urban funding organization also providing technical assistance, which is also given by WHO. TT vaccines are produced within the country and there are plans to produce other antigens. Of the 5.6% health and family planning budget, EPI finances account for only 3.56% . If all external funding were curtailed and since EPI has increased access to the government health care delivery system and decreased morbidity, EPI would be absorbed within the present allocation albeit at the expense of other programs. Local governments also share the costs, and volunteers contribute. Social sustainability relies on popular demand and political commitment. Although the Health and Family Welfare Ministry has operational responsibility, the Deputy Minister's involvement is crucial as well as the President's support. Managerial sustainability at the local level requires the same sense of ownership as at the national level. EPI was the 1st community service effort to reach large numbers of people and be appreciated.
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  11. 11

    EPI target diseases: measles, tetanus, polio, tuberculosis, pertussis, and diphtheria.

    Rodrigues LC

    In: Disease and mortality in Sub-Saharan Africa, edited by Richard G. Feachem, Dean T. Jamison. Oxford, England, Oxford University Press, 1991. 173-89.

    In Sub-Saharan Africa (SSA), 1% of all children die of neonatal tetanus, 9% of measles, 3% of tuberculosis (TB), and 4% of pertussis. Further, .6% acquire paralytic polio. 20% of the .6% who acquire diphtheria die. Even though vaccination can control these diseases, only 20% of children in SSA receive the complete course of vaccination against the 6 diseases targeted by WHO's Expanded Programme on Immunization (EPI). But high vaccine coverage is not always a cure-all. For example, in the Gambia coverage is high but high mortality levels persist. Of the EPI diseases, measles is the greatest threat since it kills 2 million people annually in developing countries. Measles related mortality is highest in the 9 months following the disease. Even though tetanus is a major cause of death in neonates, tetanus also kills adults such as those that work with the land. Further the tetanus vaccination is effective in adults, but no adult program operates in SSA. Trained midwives reduce neonatal tetanus mortality by 76.6% and vaccination of pregnant mothers with 2 doses of tetanus toxoid reduces mortality 93.3%. Lameness surveys in SSA countries show that, contrary to earlier beliefs, paralytic polio is quite common (range 0.7-13.2). Administration of the oral polio vaccine and improved sanitation are responsible for a real fall in polio cases in the Gambia, the Ivory Coast, and Cameroon. TB was introduced into SSA in the 19th century. It mainly occurs in adults. The estimated life long risk of developing smear positive TB in SSA is 63. The case fatality rate of pertussis in the 1st year of life is high (3.2) and infants do no acquire maternal immunity against it, so the best control measures are early vaccination and identifying secondary cases among young siblings. Of the EPI diseases, scientists know the least about diphtheria in SSA. Its case fatality rate is high (11-38%) yet it is treatable. Primary problems of adequate vaccination coverage for the EPI diseases are managerial problems rather than technological.
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  12. 12

    Disease in Sub-Saharan Africa: an overview.

    Ofosu-Amaah S

    In: Disease and mortality in Sub-Saharan Africa, edited by Richard G. Feachem, Dean T. Jamison. Oxford, England, Oxford University Press, 1991. 119-21.

    This article is an overview of comprehensive up-to-date accounts of the current literature on infective and parasitic diseases and malnutrition found in part II of the 1991 World Bank publication entitled Disease and Mortality in Sub-Saharan Africa. It also points out that the region has a problem with insufficient health information systems and lack of surveillance. Malaria is still a major cause of morbidity and mortality in Sub-Saharan Africa. Further the mosquito vectors become resistant to insecticides and the parasite becomes resistant to drugs. It poses many challenges to epdiemiologists, malariologist, pharmacologists, and immunologists. Yet there are not enough of African malaria scientists to address these problems. Diarrhea remains a leading cause of morbidity and mortality in small children in Sub-Saharan Africa. It includes the dysenteries, typhoid, other salmonella infections, cholera, and intestinal parasitic infections such as hookworm and ascaris. Countries in Sub-Saharan Africa need to emphasize good hygiene, safe excreta disposal, and safe water supply to prevent these conditions. Another major cause of disease and mortality in children is acute respiratory infections (ARIs) such as pneumonia. Antibiotics can treat some of these ARIs. WHO's Expanded Programme on Immunization (EPI) operates in many Sub-Saharan African countries and coverage is often high. For example, the Gambia has reached 80% coverage in children <2 years old with measles, DPT-3, BCG, polio-3, and yellow fever. Yet the 6 disease of EPI continue to afflict children. The AIDS epidemic exacerbates the burden of Sub-Saharan Africa which is already fraught with disease. Children in Sub-Saharan Africa also bear a nutritional burden (40% prevalence of stunting and 9% of wasting). Further many children also suffer from micronutrient deficiencies such as vitamin A. Other health problems in Sub-Saharan Africa include leprosy, meningococcal meningitis, and physical handicaps.
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  13. 13

    Report of a WHO Consultation on the Prevention of Human Immunodeficiency Virus and Hepatitis B Virus Transmission in the Health Care Setting, Geneva, 11-12 April 1991.

    World Health Organization [WHO]. Global Programme on AIDS

    [Unpublished] 1991. [3], 8 p. (WHO/GPA/DIR/91.5)

    The transmission of both Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) in health care settings causes concern among patients, health care workers, and national policymakers. This document reports recommendations from a consultative meeting on the issue organized by the World Health Organization Global Program on AIDS. The meeting was held at the request of member states to review risks of transmission of HBV and HIV in the health care setting, and to provide guidance on policies and strategies to minimize such risks. In order of declining incidence and likelihood, HBV and HIV may be transmitted from patient to patient, patient to worker, and worker to patient. The risk of infection depends on the prevalence of infected individuals in the population, the frequency of exposure to contaminated medical instruments, relative viral infectivity, and the concentration of virus in the blood. The risk of acquiring HBV from a needlestick exposure to blood of an infected patient is estimated at 7-30%, while less than 0.5% of health care workers exposed in similar fashion to HIV+ blood have become infected with HIV. General recommendations and specific measures for WHO and national authorities to adopt in the prevention of these infections are listed. Central to prevention is the adoption by health care workers of universal precautions which assume that all blood and certain bodily fluids are infectious. HBV vaccines for both health care workers and as a routine infant immunogen are recommended where appropriate. Routine and/or mandatory blood testing of workers or patients is not recommended, and is considered potentially counterproductive to AIDS control.
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  14. 14

    Health education: historic windows of opportunity.

    Grant JP

    HYGIE. 1991; 10(3):16-22.

    The Executive Director of UNICEF stresses at the 14th World Conference on Health Education held in Helsinki, Finland the importance of grabbing new opportunities in our changing world. An important boost to health educators is the World Summit for Children which witnessed for the 1st time world leaders committed to comprehensive and specific resolutions to improve the quality of life for children--a true opportunity to solve a global problem. Health educators can play a key role in solving global problems by showing leaders how health education can help solve these problems. Indeed political will as demonstrated at the World Summit for Children provides the needed impetus to launch a revolution of improved health for all. Now they can help convert the growing international consensus for human centered development into reality. He also points out that the success of the campaigns for universal child immunization and for oral rehydration therapy are due to health educators. Health educators should apply these successful techniques that simplifies modern medical knowledge into basic health messages which in turn empowers families and communities to save and improve lives to further improve the health of the world. A challenge that remains is promoting healthy life styles, especially among adolescents whose health problems include pregnancy, sexually transmitted diseases, and alcohol abuse. AIDS presents another challenge. Health educators need to encourage hospitals to promote breast feeding and to provide maternity services centered around the infant. Improvement in child and adult health cannot occur, however, if the people do not demand changes in society. Health educators can lead this movement by communicating and advocating healthful changes.
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  15. 15

    Indonesia lowers infant mortality.

    Bain S

    FRONT LINES. 1991 Nov; 16.

    Indonesia's success in reaching World Health Organization (WHO) universal immunization coverage standards is described as the result of a strong national program with timely, targeted donor support. USAID/Indonesia's Expanded Program for Immunization (EPI) and other USAID bilateral cooperation helped the government of Indonesia in its goal to immunize children against diphtheria, pertussis, tetanus, polio, tuberculosis, and measles by age 1. The initial project was to identify target areas and deliver vaccines against the diseases, strengthen the national immunization organization and infrastructure, and develop the Ministry of Health's capacity to conduct studies and development activities. This EPI project spanned the period 1979-90, and set the stage for continued expansion of Indonesia's immunization program to comply with the full international schedule and range of immunizations of 3 DPT, 3 polio, 1 BCG, and 1 measles inoculation. The number of immunization sites has increased from 55 to include over 5,000 health centers in all provinces, with additional services provided by visiting vaccinators and nurses in most of the 215,000 community-supported integrated health posts. While other contributory factors were at play, program success is at least partially responsible for the 1990 infant mortality rate of 58/1,000 live births compared to 72/1,000 in 1985. Strong national leadership, dedicated health workers and volunteers, and cooperation and funding from UNICEF, the World Bank, Rotary International, and WHO also played crucially positive roles in improving immunization practice in Indonesia.
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  16. 16

    Evaluation of the EPI survey methodology for estimating relative risk.

    Harris DR; Lemeshow S


    Logistical and managerial constraints have prompted classical probability-proportional-to-size (PPS) cluster sampling to be modified for application to surveys of immunization coverage. This World Health Organization Expanded Program on Immunization (EPI) methodology aims to estimate population rates accurate to within 10% of the true level. Concerned with the accuracy and reliability of the methodology, researchers have employed a Monte Carlo computer simulation model to evaluate the approach's precision in estimating relative risks. Mimicking characteristics of typical African populations, the Monte Carlo model suggests the proposed survey strategy to be a viable alternative to simple random sampling (SRS) at the 2nd stage of cluster sampling. Varying seroprevalence rate, nonresponse rate, and rate of misclassification of exposure failed to prove 1 method advantageous over the other. Given the cost and difficulty of classical sampling techniques, researchers should consider the advantages of using the EPI methodology.
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  17. 17

    Immunization 1990 success and beyond -- UNICEF and EPI Project, Bangladesh.

    IN TOUCH 1991 Jun; 10(99):21-2.

    Despite obstacles to expanding immunization coverage (EPI) in developing countries, progress has been made in Bangladesh and is described. A February, 1991, World Health Organization cluster evaluation survey indicates that government efforts during the 1980s, with the cooperation and assistance of non-governmental organizations (NGO), have increased the degree of immunization coverage in Bangladesh. 80% coverage for BCG, measles, and DPT-3 antigens is realized in the Rajshahi division, 1 of 4 divisions sampled in the survey. Use of existing FWAs and HA as vaccinators; DC, UNO, and upazila chairmen involvement; partner recruitment for mobilization efforts; steam sterilization of needles; maintenance of an effective cold chain; and monthly vaccination sessions at more than 108,000 sites throughout the country worked together to successfully yield greater immunization coverage. Sustained efforts are, however, required to ensure vaccine protection of the 4 million children born into the population each year. 80% or greater universal coverage in Bangladesh is the focus of continued efforts. Eradication of polio, measles, and neonatal tetanus is possible in the 1990s, while Vitamin A distribution and more effective promotion of family planning services are also objectives. Government and NGO workers must promote awareness of EPI, monitor EPI service delivery, and encourage HAs, FWAs, UHFO Civil Surgeons, UNOs, DCs, and upazila chairmen to provide regular EPI services.
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