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Post0227 LOGISTICS, SURVEILLANCE & DISEASE CONTROL 14 February 2000 CONTENTS 1. SURVEIILANCE LOGISTICS: SUGGESTION DURING TECHNET 2. DRAFT TECHNET'99 SUB-GROUP RECOMMENDATIONS: LOGISTICS OF DISEASE CONTROL 3. NEW PUBLICATIONS 4. POLIO CONTROL NEWS 1. SURVEIILANCE LOGISTICS: SUGGESTION DURING TECHNET The threaded emails below continue the discussions of TECHNET Forum Posts0196-0198 on logistics for surveillance and the role and function of Stop Teams and more, and follows up on the face to face discussions at Technet'99 Harare. Thanks to Maureen Birimingham, WHO/V&B, Alasdair Wylie, Ellyn Ogden, USAID, and Robert Steinglass, BASICS II for sharing this discussion. Thanks also to Marcus Hodge for his work on the draft module, and Philippe Duclos for working on the checklist. Sorry to have delayed this posting which was awaiting agreement from all participants. Action, comments and additions please: [][/email] or use your reply button ___________________________________________________________________________ From: [][/email] To: [][/email] Date: 22 December 1999 11:51 Subject: your suggestion during Technet Alidade: In addition to the logistics module, we are also revising the protocol to evaluate surveillance (which includes the same checklist). Philippe Duclos is taking the lead on the latter while Marcus Hodge (along with Mojtaba Haghgou) the lead on the former. With regard to the items regarding routine immunization you rightfully suggested should be included in the checklist for surv review/visits: We felt that instead of including those specific items in the checklist, a paragraph should be included in the evaluation protocol stating more generally, that a select set of operational issues should be reviewed during the site visits. We felt that the choice of which things to check were rather context specific and it was better to emphasize the importance of including some of these, but not to be so specific about which items to check. --- From: Alasdair Wylie To: [][/email] Date: 22 December 1999 17:22 Subject: Re: your suggestion during Technet Thanks Maureen. Clearly what needs to be checked in respect of routine programme logistics may vary from place to place, but the feeling of the group which put together the recommendation for Technet was that especially from a polio eradication perspective there is a core list of OPV/VVM related checks which should always be made by anyone making a facility visit for AFP surveillance (or, for that matter, for any other reason); this we kept as short as possible. The principle that this should be done is in accordance with the content of training of STOPpers by CDC and of Surveillance Medical Officers in WHO/SEARO. If the core list is accepted as essential, however, it follows that they should part of a checklist otherwise a) there is the risk that practice may not follow principle, b) there is no way of knowing if it is being done or not, and c) most important, if it is being done knowing what is found so that responsible local/district officials can have the information and act on it. Best regards Alasdair --- Subject: Re: your suggestion during Technet Author: "Robert Steinglass" at inet Date: 12/22/99 3:19 PM Dear Alasdair and Maureen, Gosh. I sure hope that this can be reconsidered. With some 55 items already on the checklist (if I recall correctly), it doesn't seem to me too much to add the 3 most essential (and simple) logistics items (developed at TECHNET in Harare) which are crucial if we expect to improve the quality of NIDs and logistics in general. Right now, the only time many health facilities ever get visited is as a result of NID preparation and surveillance. The meeting in Geneva last week on the effects of polio eradication on health systems development was pretty clear in that opportunities presented by polio eradication need to be seized more deliberately to improve health systems - and in this case immunization. I think it would be a serious missed programmatic opportunity not to include a few logistics questions - - not only to improve the logistics for the routine EPI but to improve implementation of the NID itself. Robert Robert Steinglass Immunization Team Leader BASICS 1600 Wilson Blvd., 3F Arlington, VA 22209 USA voice: 1-703-312-6800 fax: 1-703-312-6900 e-mail: [][/email] --- From: , on 12/23/1999 7:46 AM: I think there is some confusion. There is no disagreement that opportunities should be seized to check logistics/operations whenever out in the field. There is no disagreement that active surveillance visits for polio should check routine issues. There is no disagreement that even surveillance reviews shouldn't check other issues (logistics, safety, issues for several diseases). We are suggesting that we add a paragraph stating such, but that the actual items to check may vary from country-to-country and should be adapted accordingly. Please note that the protocol I mentioned is for a one-off evaluation of surveillance (which might be multi-disease, might be focused on polio or measles or something else) is different from active surveillance visits (which is routine/ongoing) for AFP/polio. This protocol is meant to be quite generic. --- Subject: re: Re[2]: your suggestion during Technet Author: "Ellyn Ogden" at inet Date: 12/23/99 1:07 PM Maureen/Alasdair: I appreciate being cc'd on this discussion. It is certainly good to read that there is no disagreement that logistics/operations need to be checked by surveillance officers. It seems like this is a dissemination issue: how do we get this checklist into the hands of surveillance officers quickly? 1.) The logistics module should include the checklist; but this module won't necessarily get into the hands of the surveillance officers; 2) The Assessment tool is a one-off evaluation protocol that ought to include aspects of the management information system needed for effective surveillance. The tool should be able to assess the current capability of the system to monitoring the cold-chain, vaccine wastage, stockflow/stockout, etc. and determine how well this information is being shared/used by surveillance officers. But this too doesn't seem like the best mechanism for disseminating the checklist that Alasdair is proposing. 3.) What other mechanisms are there? Is it possible to issue a supplement to the polio field guide? A one-page "Technical Update" for surveillance officers/polio eradication program staff? other? In addition to the short essential list of things Alasdair suggested, I would also add a few. I have very little "logistics experience" yet I've tried to make a point of stopping for 15 minutes at the cold stores and asking the following questions. I include the responses in my trip reports and in my debriefings with MOH staff. I don't know if it helps solve the problems, but it gives the logistics people a sense that they are part of the bigger program; shows someone is interested in their role in the program/health worker motivation; and offers the potential to raise issues outside of the "regular channels" that they need to work within. Ellyn's FAQs -- are there stockouts of vaccine (how frequent, how long, responsiveness of system to fill requests)? -- is the power supply regular? frequency of outages? is there a backup generator? who's responsible for checking? -- what proportion of equipment functioning? -- what proportion of equipment needs repairs? how long have they been waiting? -- ask to see the temperature records -- ask if they note the condition of the VVM when they accept the vaccine/disburse the vaccine -- what is their role during NIDs? were they included during microplanning? FYI, from experience I know that if something is described in a paragraph it is less likely to get the attention it deserves -- lists are much better for people with little time to absorb and digest information. I would propose that you consider crafting a list that would include two categories: "Strongly recommended" and "Recommended." This would still let countries pick and choose, while at the same time prioritizing those elements that WHO/Technet/Polio program considers essential and fundamental to the program. A paragraph could be used to provide information on the impact of poor performance and provide guidance on what to do with the results. Thanks to everyone for trying to push this forward. regards, Ellyn --- From: [][/email] To: [][/email] ; ; [][/email] Date: 03 January 2000 18:51 Subject: Re[4]: your suggestion during Technet Philippe: As you are taking the lead on finalizing the surveillance evaluation module, perhaps we could put in a supplement checklist as an example of other important things to check related to routine immunizations when out in the field. I agree with Ellyn that a paragraph is less likely to be noticed then perhaps an example "supplemental checklist" in an annex with a footnote stating how this must be adapted to situation at hand. Thanks to all for your useful comments. ____________________________________*______________________________________ 2. DRAFT TECHNET'99 SUB-GROUP RECOMMENDATIONS: LOGISTICS OF DISEASE CONTROL During Technet'99 the Sub-Group prepared these recommendations on the logistics of disease control. ___________________________________________________________________________ DRAFT 2 Recommendation 9/12/99 (Re: Session 2 Logistics of Disease Control) Supervision tasks during AFP surveillance: 1. In line with WHO's approach to the training and posting of Surveillance Medical Officers and CDC's approach to the training of "STOP" epidemiologists for AFP surveillance* , all visits made for AFP surveillance to health facilities which store vaccine should include a minimum list of vaccine inspection checks. 2. The proposed list is: How many doses of OPV in stock? Are all vials within expiry date? Are all VVMs before discard (end) point (stage 1 or 2)? If No, how many vials with VVM at stage 3 ; at stage 4. ? 3. The results of this check, (along with the results of the other AFP supervisory visit tasks/checks) must be given to the District level public health/medical officer responsible for supervision of the facility concerned. 4. The supervisory checklist in the draft "New logistics for surveillance module" (Technet.99/Session 2/ WP4 Annex 4) should include, in addition to the existing component "Evidence of a good reverse cold chain" , a component "Evidence of good vaccine cold chain" with the above list of checks. --------------------------------------------------------------------------- Role of the STOP Teams --------------------------------------------------------------------------- * "The STOP teams are expected, while doing their routine AFP surveillance work, to inspect refrigerators, look at the OPV and the VVMs (teach about VVMs if the staff is unaware) and keep a record of their findings which are then given to the MOH/WHO. They are also taught to look at the cold boxes for specimen transport to ensure that they have a proper cold box (reverse cold chain). All of this is considered a vital part of the surveillance system." ____________________________________*______________________________________ 3. NEW PUBLICATIONS ___________________________________________________________________________ Date: Thu, 27 Jan 2000 14:28:16 -0500 From: Meagan Cooke The following books are currently available from the Pan American Health Organization. "Hantavirus in the Americas: Guidelines for diagnosis, treatment, prevention and control." -- This comprehensive manual begins by describing the different hantaviruses known in the Americas and their reservoirs, rodent ecology and zoology, and the epidemiology of human disease in the Region. Upon this foundation, the manual describes the disease's clinical manifestation and diagnosis and presents guidelines for HPS surveillance, treatment, and case management. It also provides detailed, easy-to-follow instructions for preventing infection in the home, hospital, and laboratory, as well for cleaning rodent-infested areas. The importance of educating health professionals and the general public about the disease is stressed through examples of communication strategies used in different countries of the Region. The publication also provides an overview of communication tools that can be adapted to educate diverse populations about HPS and other communicable diseases. An essential tool for anyone involved in hantavirus prevention, control, treatment, or health education activities, "Hantavirus in the Americas" contains useful, stand-alone annexes, such as sample case report forms, guidelines for safe handling and transfer of specimens, educational resources, and descriptions of prevention campaigns undertaken by countries in the Region. The book's handy format allows for quick reproduction and distribution of the annexes and infection prevention and control measures. ISBN 92 75 13047 7, US$ 14.00, 65 pp. "Measles Eradication--Field Guide." -- This publication outlines PAHO's strategy for becoming and remaining measles-free and also provides valuable background information about measles in a concise format and easy-to-understand language. Its seven chapters cover such subjects as the epidemiology of measles, clinical aspects of the disease, proper handling and delivery of measles vaccines, and methods of laboratory confirmation of measles infection. The rationale and activities related to the vaccination strategy are explained in depth. The largest section of the book is devoted to surveillance for measles cases and gives guidelines for case investigation, outbreak response, and other components of an effective surveillance system. Attached as appendices are numerous examples of forms that can be copied and modified as needed for local surveillance purposes. There is also an extensive bibliography arranged by subject. The practical information contained in this manual will benefit public health personnel and medical practitioners at all levels. The field guide is an essential tool for anyone involved in administering or carrying out vaccination programs, both in the Americas and elsewhere. ISBN 92 75 13041 8, US$ 14.00, 70 pp. Both titles are also available in Spanish. For more information, contact PAHO at email: [][/email] fax: (202) 206-0869 web: Meagan Cooke Publications Program Pan American Health Organization 525 Twenty-third Street, NW Washington, DC 20037 e-mail: [][/email] ____________________________________*______________________________________ 4. DISEASE CONTROL NEWS ___________________________________________________________________________ "Woman Has State's First Measles Case Since 1998" Associated Press (02/06/00) The first case of measles in Ohio since 1998 has been detected in a college student at Columbus State Community College. The disease could have infected her classmates or co-workers, as measles is airborne and is highly contagious. Symptoms include high fever, large spots and rash. The two-dose vaccine for measles is recommended for anyone born after 1957; measles was so widespread before that year, that most people contracted the disease and now immune to it. --- "Afghanistan: Measles Epidemic" New York Times ( (02/05/00) P. A5; Crossette, Barbara An outbreak of measles in a remote part of Afghanistan has killed 100 people, according to the United Nations. The epidemic started in the northern Samangan Province, a region which saw heavy fighting between the Taliban and the opposition alliance in 1999. --- "Gates-Funded Vaccine Drive Woos Allies" Reuters (01/31/00) The Children's Challenge, a vaccination drive funded by Microsoft Chairman Bill Gates and other business leaders and agencies, is asking for donations to help inoculate children across the globe against common diseases. The drive was launched by the Global Alliance for Vaccines and Immunizations, and the Bill and Melinda Gates Foundation has already pledged $750 million over five years to help. According to World Health Organization Director-General Gro Harlem Brundtland, it costs $17 a child to protect them against polio, diphtheria, tuberculosis, pertussis, measles, and tetanus,. Almost 3 million children die every year from vaccine-preventable diseases. --- "Protein on TB Bacteria May Hold Key to New Treatment" Reuters Health Information Services (01/31/00) Researchers, led by Dr. James Sacchettini of Texas A&M University, have found that a protein complex called antigen 85c can show potential targets for tuberculosis (TB) vaccines or drugs. Sacchetini's team studied the structure of antigen 85c and discovered how the protein helps TB infect immune system cells. The current TB vaccine is often not effective, but the new information may help make a better vaccine. The researchers report their findings in the February issue of Nature Structural Biology (2000;7:94-95,141-143). --- "15-Year Follow-Up Shows BCG Vaccine Is Not Effective in India" Lancet (11/06/99) Vol. 354, No. 9190, P. 1619; Kumar, Sanjay Findings from a 15-year follow-up of a large randomized study of the BCG vaccine conducted in Chingleput district, India, indicate that BCG provides no protection to adults and only slight protection--about 27 percent--in children against pulmonary tuberculosis (TB). The original study involved 280,000 people of various ages who were given Danish 1331 and French 1173P2 strains of BCG. The groups did not exhibit any significant difference in TB rates. The researchers concluded the vaccine was unlikely to reduce transmission rates. In response to the new findings, which confirmed follow-up analysis done at 7.5 years, V. Ramalingaswami, former director-general of the Indian Council of Medical Research (ICMR), noted the data did not address whether the vaccine was effective against childhood forms of TB, such as tuberculous meningitis and miliary tuberculosis. ICMR deputy director-general Lalit Kant disregarded the findings and said the BCG vaccine had helped reduce the incidence of childhood forms of TB. --- "Impact of Immunisation on Pertussis Transmission in England and Wales (Research Letter)" Lancet ( (01/22/00) Vol. 355, No. 9200, P. 285; Rohani, Pejman; Earn, David J.D.; Grenfell, Bryan T. Researchers from the University of Cambridge, England, have found that vaccination for pertussis has reduced transmission in England and Wales. After analyzing high-resolution pertussis notification data, the researchers found that mass vaccination caused a significant decrease in reported cases of pertussis. The scientists also looked at the efficacy of vaccination, and found evidence that immunizations has reduced transmission of the disease, not just lowered disease frequency. --- "Diphtheria in Urban Slums in North India (Research Letter)" Lancet ( (01/15/00) Vol. 355, No. 9199, P. 204; Lodha, Rakesh; Dash, Nihar R.; Kapil, Arti; et al. Cases of diphtheria in India reported in 1997 numbered 1,326. In September 1999, four children from different families in urban slums of northern India came to the India Institute of Medical Sciences with diphtheria. The children had sore throat, fever, dysphagia, and neck swelling for two to 10 days. Two children were not immunized, and the other two had received only two doses of the diphtheria-pertussis-tetanus vaccine. Two children died within hours of admission because of arrhythmia. These four cases seen within the same time frame represent a resurgence of diphtheria, caused by a decline in immunizations, poor conditions, and overcrowding in the slums. --- "Progress Toward Poliomyelitis Eradication--Chad, 1996-1999" Morbidity and Mortality Weekly Report ( (01/28/00) Vol. 49, No. 3, P. 57 The World Health Organization resolved in 1988 to eradicate poliomyelitis globally by the end of 2000. Chad, in central sub-Saharan Africa, has made some progress towards this goals since 1996, after three decades of civil war and poor health services. In the past decade, routine infant vaccinations were estimated at 10 percent to 25 percent; however, National Immunization Days, begun in February 1997, have worked to administer the polio vaccine to 90 percent of the children under age five during each round. Chad collected information on confirmed cases of paralytic polio, which declined from 402 cases in 1995 to 326 in 1997. In 1999, 182 polio cases were reported and 82 were confirmed, after the Ministry of Health (MOH) formed the national service of integrated active surveillance in May of 1999. Chad's MOH has grown more successful in implementing recommendations for polio vaccination, and will focus this year on vaccinating nomadic groups and individuals in populated areas of southern Chad. --- "Over 700,000 Liberian Children to Get Polio Vaccine" PANA Wire Service (01/26/00); Kahler, Peter A polio immunization campaign in Liberia, "Polio Out of Liberia," has vaccinated 750,000 children since Monday. President Charles Taylor launched the campaign Monday, stating they are determined to eradicate polio from the country. Taylor noted that he has a sister with the disease and knows first-hand "the devastating affect of polio." Health Minister Peter Coleman also reported that over 160,000 Liberian children have contracted the disease. The immunization campaign is part of an effort to eradicate polio worldwide. ---- "Flu Shots May Benefit Children" Washington Post ( (01/27/00) P. A5 Two studies published in Thursday's New England Journal of Medicine suggest that both healthy children and those who are at "high-risk"--meaning those children with asthma, diabetes, or other chronic conditions--are infected with influenza too often. The information led the researchers to suggest that the flu vaccine be considered for use in children; however, the scientists from the Centers for Disease Control and Prevention and Vanderbilt University did not give a flat recommendation for the shot. Children are currently vaccinated for up to 16 diseases before the age of two, and questions remain about the cost-effectiveness and logistics of vaccinating all children against a different flu strain each year. ____________________________________*______________________________________

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