Post00351 : MEASLES PLUS

Post00351 MEASLES PLUS 18 June 2001 CONTENTS 1.FIELD EXPERIENCE GUIDES PAHO'S VACCINE DIRECTOR: LESSONS FROM THE FIELD Tip of the hat to Bob Davis, UNICEF for this Lancet Interview With Dr Ciro De Quadros. "De Quadros thinks now is the time to start moving towards global measles eradication. Many in the field think it is too soon to start. Measles, they point out, is extraordinarily contagious. To eradicate the virus would require vaccine coverage of 95% or higher, something far beyond the capacity of many developing nations. But de Quadros believes it can be done. The first step, he says, would be to add the measles vaccine to the current regimen being distributed as part of the polio eradication effort. This would increase the distribution of the vaccine in sub-Saharan Africa, where some 500 000 children die each year from the disease. In 2-3 years, measles mortality would be halved, he says, and when polio eradication is complete, the world would be well on its way towards measles eradication as well. With enough resources and some luck it might be possible to wipe out measles as early as 2015, he says." Opinion, comments and additions please: [log in to unmask] or use your reply button ___________________________________________________________________________ http://www.thelancet.com/ ___________________________________________________________________________ Feature The Lancet Volume 357, Number 9271 09 June 2001 Field experience guides PAHO's vaccine director When he was a young medical student in Brazil, Ciro de Quadros decided he wanted to go into public health. So he went to visit the National School of Public Health. There he met a professor who told him not to come straight to the school of public health. "He said: 'Go out first and work in the field, experience real life, and then no one here will be able to mislead you'", de Quadros recalls with a laugh. De Quadros, a warm and earnest man, who now directs the Pan American Health Organisation's Division of Vaccines and Immunisations, took the advice and found that professor was right--the place to learn about public health was in the field. He joined the Brazilian Special Service of Public Health and soon he found himself working as the chief medical officer of a public health centre in Altamira, a small town of 5000 people in the Amazon rainforest. "We had just one doctor, one nurse, one sanitarian, one lab technician, one health educator, and one administrator. We had to do everything: general practice, minor surgery, and, of course, the public health work." This included everything from improving the town's water supply to tracking down tuberculosis cases. But one of his main concerns was vaccinating the children. To keep his team focused, he kept a chart showing each month how close they were to reaching their target of full immunisation. "At the end of the year", de Quadros says with evident pride, "we had everyone vaccinated." He learned what a small but organised and dedicated team could do--and that the solutions to many problems will come not from the main office but from workers in the field. "My field experience has taught me to listen to fieldworkers", he says, "and you have to pay attention to everybody, because you cannot predict who will come up with the good idea." De Quadros went back to school and got his masters in public health. But he soon found himself in the field again, this time as the smallpox surveillance officer for the state of Parane in southeastern Brazil. It was 1969 and Brazil was conducting mass vaccination programmes against smallpox. But funds were not yet available for Parane, so de Quadros was to use the opportunity to test a new vaccine strategy called surveillance and containment. At the time, it was generally believed the only way to eradicate smallpox was to try to vaccinate everybody with mass vaccination programmes. But vaccinating teams responding to outbreaks in Africa and Asia found that if they detected cases quickly and promptly vaccinated everyone around them, it was possible to prevent the virus from finding new hosts, ending transmission. To test the approach in Parane, a sprawling state with an area of nearly 200 000 km2 and a population of 8 million, de Quadros was given a car and a nurse vaccinator. LESSONS FROM THE FIELD Michael McCarthy Together they began to chase down outbreaks reports. "When we found a case, we started vaccinating everybody. We had jet injectors so we'd set up on street corners and call to people. We would go to the schools. We would use the local radio station and drive around in cars with megaphones mounted on the top. You would use all means necessary, and in 2-3 days you could organise a town--because people were really scared." The team identified more than 1000 cases and vaccinated more than 38 000 people before the mass campaign got going. When the campaign finally started, vaccinators went house to house. They failed to find a single case of smallpox. Surveillance and containment had worked: vaccinating just 35 000 people had eradicated the virus from a population of 8 million. De Quadros' work had caught the attention of D A Henderson, director of the WHO smallpox eradication programme, who asked him to become the field operations director of the new eradication programme starting in Ethiopia, the first that would use surveillance and containment from the start. At the time, half of country's 22 million citizens lived more than a day's walk from any road. The terrain was rugged and the population was often suspicious of vaccination workers. "You could go walking through those mountains for days and days to find a smallpox case but then you could not vaccinate anybody because nobody wanted the vaccination. They would throw stones. They would set dogs on you", de Quadros remembers. He stayed in Ethiopia for 6 years, leaving in 1977, 6 months after the last case had been found in the country. De Quadros then joined PAHO and became the first director in the Americas of the Expanded Program on Immunisation, a plan to use the expertise and infrastructure built up during the smallpox eradication campaign to promote immunisations against polio, measles, diphtheria, pertussis, tetanus, and tuberculosis. He went on to play a key role in the PAHO-sponsored programme that eradicated polio from the Americas in 1991 as well the ongoing campaign, which will, he predicts, eradicate endemic transmission of measles from the Americas this year. De Quadros thinks now is the time to start moving towards global measles eradication. Many in the field think it is too soon to start. Measles, they point out, is extraordinarily contagious. To eradicate the virus would require vaccine coverage of 95% or higher, something far beyond the capacity of many developing nations. But de Quadros believes it can be done. The first step, he says, would be to add the measles vaccine to the current regimen being distributed as part of the polio eradication effort. This would increase the distribution of the vaccine in sub-Saharan Africa, where some 500 000 children die each year from the disease. In 2-3 years, measles mortality would be halved, he says, and when polio eradication is complete, the world would be well on its way towards measles eradication as well. With enough resources and some luck it might be possible to wipe out measles as early as 2015, he says. But many in the polio eradication programme are wary, feeling that introducing a measles vaccine will only draw resources away from the polio programme that is already seriously underfunded. De Quadros disagrees. In fact, he thinks adding the measles vaccine will actually help the polio campaign. "People in these countries fear measles more than polio", he points out, because while "polio maims, measles kills". Looking over his reading glasses and raising his eyebrows, de Quadros continues, "so a measles vaccine could serve as a sort of 'bait'--an incentive to draw people in." That's a fieldworker talking. Michael McCarthy ___________________________________________________________________________ Selected news item reprinted under the fair use doctrine of international copyright law: http://www4.law.cornell.edu/uscode/17/107.html ____________________________________*______________________________________