EPI NewsletterExpanded Program on Immunization

in the Americas

Volume II, Number 5 IMMUNIZE AND PROTECT YOUR CHILD October 1980

Epideniology Table 1

Observations on an Outbreakof Measles in Serrana Municipality,Sao Paulo State. Brazil

Hospital ized Measles Cases Reported in Novemberand December 1979 and January 1980 among ResidenLs

of Serrana Municipality, sao Paulo Stale

During December 1979 the district public healthteam of the Ribeirao Prelo subregion began Lo bealarmed at the relatively large number of hospitalizedmeasles cases reported among the resident population ofSerrana Municipality, one of the twelve lowns in thehealth district.

The first case occurred in November 1979 and theothers were repar ted during December. except for onewhich was reported in January 1980. The shape of theoutbreak is illustrated in the following bar chart:

Age Group

Under 1 year1 to 4 years5 La 14 years

Total

Number

152

8

Cases

%

12.562.525.0

100.0

Graph 1

Number of hospitalized measles cases inNo ... ember ond December 1979 and January1980. MunIcipality at Serrano, Sao Poulo Stole.

EPIDEMIOLOGY

Index

5

6Domin ican

- Observations on an Outbreak ofMeasles in Serrana Municipalicy,Sao Paulo State, Brazil .....

- Measles: Uniced Staces. First 39Weeks of 1980 . . . . . .

- Poliomyelitis:Republic. 1980

It was found that one case (12 ~ percent) had def­initely been vaccinated against mec:sles, three 07.5percent) had not been vaccinated. and in four cases (50percent) the vaccination history was un1\Oo',,", Thesefigures are shO'Wn in Table 2.

Source: Boletim Epidemio16gico Semanal <Iudepidemiological records.

Date of onset offirst symptoms

10 November 197901 December 197903 December 197903 December 197910 December 197916 December 197923 December 197917 January 1980

JAN.DK.NOV.

8

7

6

54

3

2

1

OL...--

V>LUV>«u

1979 1980

MONTHCOLD CHAIN

Six (75 percent) of the eight hospitalized caseshad broncho-pneumonia as a complication.

- Developing Alternatives for the Solutionof Cold Chain Problems. . • . .. 6

Dividing the cases among theirillustrated in Table I, one finds thatyear aIds accountE'.d for 62.5 percent of

age groups. asthe one to fourthe cases.

REPORTED CASES OF EPI DISEASES INTHE AMERICAS. .. . ..••. 7

2

Table 2 Tabte Ii

Vaccination History of the Hospitalized MeaslesCases, by Age Groups, Serrana. Slo Paulo State

Distribution of Cases of Measles among Infants underOne Year, by Age in Months, During the Outbreak of

Heasles in Late 1979 and January 1980 in the Town ofSerrana, SDo Paulo StaLe

Under 1 year 1 12.5 1 12.51 LO 4 years 12.5 2 25.0 2 25.0 5 62.55 Lo 14 years 1 12.5 1 12.5 2 25.0

Total 1 12.5 3 37.5 4 50.0 8 100.0

Source: Boletim Epidemio16gico Semanal andepidemiological records.

Not Vac­Vaccinated cinated Unknown

12.5

2 25.0

3 37.51 12.51 12.5

8 100.0

%No. of CasesAge

1 month2 months3 mon ths4 months5 months6 months7 months8 months9 months

10 months11 months

Total

No. %

Total

%No.%No.No.

Age Group

These data pointed to an outbreaK of measles. whichwarranted an investigation to determine the real situa­tion 50 that practical and effective control measurescould be laken.

It .... i 11 be noted that three of the eight cases(37.5 percent) were infants under nine months of age,and eight of the 140 cases (5.7 percent) were under oneyear of age.

comprised the months of NovemberThe period studiedand December 1979 and1980. The survey ofcommun i ty cons is led 0 fabout cases of measlesperiod in question.

up to the 28th day ofthe occurrence of casesa single house-to-houseand other pertinent data

Januaryin the

inquiryfor the

Among the 140 cases there were three deaths frommeasles, which gave a case fatality rate of 2.1 percentand a mortality rste of 34.7 per 100,000 inhabitants.One of the deaths was of an infant under one year ofage and tw were in the one-to-four year group. Nodeaths occurred among the hospitalized pa t ients.

It ....as found at the outset that seven of the eigh tmeasles cases hospitalized during those months camefrom the same quarter in the tovn of Serrana: the onemost distant from the center and inhabitated by thepoorest members of the community.

Table 3 itlustrates the distribution of the measlescases discovered, by age group, and the attacK Tatesbased on the estimated population.

Table 3

The age distribution of the cases is given in Graph2, which shows the nUlDber of cases at each year ofage. The graph shows that the age group most heavilyattacked was that of children bet ....een one and eightyears old. This does not bear out the conventional.... isdom that children bet ....een the ages of 18 and 30months are the most frequently attacked in measlesepidemics, particularly among the more indigent popula­tions, as was the case in Serrans. Horeover, the out­break occurred during the Sl"IJlmer months, which is notsurprising in hot areas where the disease is endemic.

Cases of Measles Occurring in November and December1979 and January 1980. by Age Groups, Estimated

Associated Populations, and Attack Rates per tOO.OOOResidents of the Town of Serrana, SDo Paulo

G,oph 2Number of measles cases, by age In years, wh,ch occurred 10 thecIty of Serrano, S60 Poulo Stole. during the months of Novemberond December 1979 and January 1980. Total: 140 cases.

Age Croup No. of Es tilnated AttackCases Population RaLe

o to 4 years 57 1,189 4.85 Lo 9 years S6 1.242 4.510 Lo 14 years 23 1.130 2.0

~

15 years and older 4 5,096 0.8 w~

'"UToLal 140 8,657 1.6

Source: Household epidemiological survey.

The ages in months of the cases among infants underone year of age are given in Table 4.

·1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+

AGE

In the survey to detect cases among the population,an attempt was made to discover the measles vaccinationhistory of each individual; the results are presentedin Table 5. As can be seen, the proportion of measlescases among vaccinated individuals was relatively high(17.1 percent). In 68.6 percent of the cases the pa­tient had not been vaccinated, and in 14.3 percent thevaccination history was unknown.

Table 5

vaccination History of Measles Cases Occurring inNovember and December 1979 and January 1980.

by Age, among Residents of Serrana Municipal ity,SAo Paulo State

3

A more detailed study was performed in order tocorrelate the ages at which the patients had been vac­cinated against mEasles and the ages at which they con­tracted the disease. The results are given in Table 6.Rough 1y speaking, four cases may be disregarded becausethey were vaccinated at the same agE at which they con­tracted measles-one at nine months, one at one yearand two at two years of age. Since the preciSE dateson which they were vaccinated and on which thev con­tracted the diSl!8se are unknown, it cannot be r;liablydetermined whether the infection emerged before thevaccination could confer immunlty (assuming, of course,that the vaccine administered was potent).

Disregarding the four cases who caught measles atthe same age at which they -..ere vaccinated, thEre re­main 14 cases out of 20 (70 percent) who were vac­cinated at the age of seven months or younger and whothen contracted the disease.

The vaccination coverage was found to bE adequa:ein the one-to-four year age group, but inadequatE- inthose unde r one yea r 0 f age and low in the f i ve- to­fourteen year age group. This can be seen in Table 7which illustrates the results of a survey among 726inhabitants of the area of the town at highest risk ofinfection.

Table 7

Coverage of Measles Vaccination in a Sample of Residentsof the Highest Risk Area in Serrana. Sao ""aulo State,

January 1980

No. VaccinatedAge PopulationGroup Studied dose %

Under 1 year 12 4 33.31 to 4 years 88 59 67.05 to 14 years 211 34 16.115 years and + 415 0

Boosler %

11 12.5..2 0.9o

Total 726 97 13.4Source: Household investigation.

13 1.8

Table 6

Comparison between Age of Vaccination against Keasles and Age atwhich the Disease was Subsequently Contracted - Cases During Novemb~r

and December 1979 and January 1980. SetTana, Sao Paulo Stale

Age at vac­cination

2 Months 6 Months 7 Months 8 Months 9 Months 10 Months 1 Year 2 Years Total

Age at No. % No. % No. % No. % No. % No. % No. % No. % No. %i 1lness

9 months 1 4.2 1 4.21 year 1 4.2 4.2 2 8.32 years J 12. OJ 2 8.3 5 20.83 years 1 4.2 1 4.24 years 1 4.2 3 12.5 4 16.75 vears 2 8.3 2 8.3 4 16.76 years 1 4.2 4.2 2 8.37 years 4.2 4.2 4.2 4.2 4 16.78 years9 years 4.2 4.2

10 years and •

Total 4.2 3 12.5 10 41.7 4.2 2 8.3 4.2 3 12.5 3 12.5 24 100.0

Source: Household epidemiolnKical survey.

4

The survey data in Table 7 on children under oneyear of age diverge markedly from the data on childrenin the same age group vaccinated during 1979 in theentiree. population, according to information of thelocal heal th unit as presented in Table 8.

boos ter shots were given to individuals between one andfourteen years of age, as shO'JTl in Table 9.

Table 9

Source: Records of the local hee.alth unit.

*Beginning at seven months of age.

Distribution of First Dose and Booster Shot ofMeasles Vaccine Administered, by Age Group,

Between 17 and 28 January 1980 in Serrana.510 Paulo State

Of the 238 doses of vaccine administered, 122 C51.3percent) were given on the premises of the local healthunit and 116 (4B.7 percenr) in epidemiological fieldwork.

1st dose Boos ler

No. % No. %

36 30.570 59.3 58 48.312 10.2 62 51. 7

118 100.0 120 100.0Total

Age Group

Under 1 year*1 to 4 years5 to 14 years

Table 8

Monthly Measles Vaccination Coverage of Childrenunder One Year 0 f Age* Dur ing 1979 in Se n' ana,

SAo Paulo State. Population OfficiallyEstimated at 219 Children

Cumula t iveMonth No. Vaccinated Percentage

J anusry 10 4.6February 18 12.8March 24 23.7April 19 32.4May 18 40.6June 25 52.0July 38 69.4Augus t 28 82.2September 32 96.8October 29 110.0November 46 131. 0December 25 142.5

Total 312 142.5

Monthly Average 26 11.9

*Vaccination performed beginning at seven months of age.

Source: Vaccination records of the local health unit.

According to the previous table, the vaccinationcoverage of ch ildren under one year of age was ex­cellent, even having exceeded the officially estimatedpopulation in the age group. This excess lD8y be ac­counted for by the influx of immigrants from ruralareas in the neighboring states of Minas Gerais andParan4, attracted by extensive cane plantations and alarge sugar mi 11 opera ting in the area.

The percentage of unvaccinated individuals in theRibeir:to Pre to region remains high for two reasons:measles vaccination was only ree.ce.ntly begun (in 1971)and its administration has been predominantly static.Moreover, until 1979 all children seven months and olderwere given only one dose. At the end of 1979 this prac­tice was modified to include the administration of abooster shot, beginning at 15 months of age, to allchildren who had nceivee.d theiT firs:. dose before reach­ing one year of age.

Source .. Germano Neto, J., public health physician,Technical Director; Freitas S.B., public healthnurse; and Santos, M.T., public health edu­cationist, all of RibeirlO Preto, HealthDistrict, SAo Paulo, February 1980.

Ed i tor' 5 Note

A study to determine the optimum age for measlesvaccina tion is in progress under the auspices of PARO/­WHO and four Latin American countries, including Brazil(see Boletim Epidemiol6gico XI(14), 1979). 'nlis studyis necessary because, unlike temperate-zone countrieswhere hereditary immunity is retained for up to one yearor slightly longer after birth, Ln tropical countriesit is lost earlier.

In any event., it is clear that a substantial partof the population under one year of age residing in themeasles outbreak area undee.r cons idera tion did not re­ceivee. thee. preventive care offend by thee. Secretariatfor Health. Actually, such pockets of unvaccinatedresidents of poor urban areas are not uncOlDl!lon. even inhighly developed countries, as has been wee. I I documentee.din the lite.rature.

In view of a clearly epidemic situation, the dis­trict health team decided to intensify its vaccinationagainst measles. particularly among the populationregarded as being at highest risk by the standards ofthe Epidemiological Surveillance System of the StateSecretariat for Health. Susceptible children betweenseven months and five years of age were vaccinated and

Source .. Boletim Epidemioldgico XTI(S}:q2-51,published by the Funda).io Serv i)-os dePt1blica, Ministl!rio da Sat1de, Brasil.

1980,sat1de

5

Measles: United States,First 39 Weeks of 1980

reported numbers of casea have been record lows, and the23 cases reporled in week 39 were the fewest everreported for a single week.

+Through the 39th reporting week.

++ 3-week period

1979.1980'

Figure 2

Reported measles cases, by 4-week period,

3,2003,0002,8002,6002,4002,200

~ 7,000':;: 1,800u 1,600

1,4001,2001,000800600400200

O'L--:-~---t.:;--t-~~---t;--:t:-~~,.. , 8 12 16 20 24 28 32 36 39"

4·WE EK PE RIOD

Figure 1

U.S. Counlles· with measles, week ending 27 September 1980(39 th reporllng week)

As of 27 September 1980 (the 39th reporting week),investigations by ilDIDunization project} staff re­vealed only one aetive chain of transmission2 of mea­sles in the United States. Projects in 15 other coun­ties throughout the country reported isolated cases thatwere not associated with document ed spread (Figure 1).

-In CALIFORNIA: Conlro (0510, Glenn, Imperiol, Los Angeles, San Diego,Son Francisco, and Tulare counlies; FLORIDA: Broward and Pinellascounlles; ILLINOIS; Mclean; MISSOURI: Gentry; NEW YORK: Kings; OHIO·

Columblono; TEXAS: Harris and Uvalde; VIRGINIA: Warren; WISCONSIN:Marathon.

Thirty-one Slates and the District of Columbia havenot reported any measles cases in the last four weeks.Since 1 January 1980, 41 states and the DistriCl ofColumbia have not reported any cases of measles for atleast a 4-week peI"iod. Only Arizona, California,Florida, Illinois, Minnesola, New York, Ohio, Texas,Wisconsin, and New York City have not had as many asfour consecutive measles-free weeks this year.

The single outbreak, which began 9 September and isslill being investigated, occurred in Warren County,Virginia. The index patient was a lS-year-old girl, whohad been exposed to the disease in England. A rashdeveloped after she returned to Virginia on 9 September.Four of her siblings subsequently had onset of measlesfrom 18-21 September. An additional 27 suspected cases--all in persons attending the same private day schoolin Rappahannock County--are being investigated in fivecontiguous counties.

Nationwide, 12,881 cases of measles ..ere reportedfor the first 39 weeks of this year. This is secondonly to last year's total (12,207) as being the lowestever recorded for a cnmparable period. Actually, theinc i.dence of measles this year has been lower than in1979 for all periods except 23 Harch-12 July ( ..eeks13-29, Figure 2). For 9 of the last 11 weeks, t.he

lSlate or local health jurisdictions which have beenawarded federal funding for immunization programs.

2An active chain of transmission is one in which thereare two or more epidemiologically linked cases, andless than four weeks has elapsed since onset of rash inthe last known case.

During the first 39 weeks of 1980, 20 states had ameasles incidence of >10/100,000 among persons <18 yearsold, whereas 24 stales reported such rates in 1979.Thus far in 1980, nine states have reported a measlesincidence of <1/100.000, as did only five states in thesame period last year.

Repnrled by H.S. Wood, MO, G.A. Dengel, MD,P.O. Pedersen, MD, Warren County Health Dept;J. Einardon, MD, Rappahannock County, Virginia;G. Hiller, MD, State Epidemiologist, VirginiaState Dept. of Health; and Immunizalion Div., Bur.of State Services. CDC.

Editorial Nole

The record low numbers of reported cases of measlesin recenl weeks and the fact that there is only oneknown active chain of transmission in the United Statesindicate that transmission of measles has been inter­rupted throughout most of the country. Intensivemeasles outbreak control efforts are thus even moreimporlant in the few areas slill reporting measles.Prcmtpt attention should be paid to reports of isolatedcases since they may develop into continuing outbreaks.An integral part of measles outbreak conlrol programsshould be the exc Ius ion of students who do not havevalid evidence of measles immunity not only from the

Morbidity and Horlality Weekly Report 29(40):501-502, 1980. Center for Disease Control,Public Health Service, Atlanta. Georgia.

schools reporting measles cases,schools in the area that are.introduction).

Source:

butat

alsorisk

from otherof measles

6

Table 3

Vaccination history of caResof paralytic poliomveliti.

Dominican Republ ic: 1 Januarv - 30 September 1980

No. of dose.!'! No. of caReR %

TOTAL

"Poliomyelitis: Dominican Republic, 1980

Between 1 Januarv and )0 September 1980, a total of93 ca~el'l of paralytic poliomyeliti~ were reported inthe Dominican Republic. TheRe easeR came from II ofthe countrv'~ 27 provincel'l; their monthly dil'ltributionLS shown in Table 1. The highest number of ca<;eRoccurred in Jul y and led to stepped-up cont.ro1actiyitieCl.

Tab Ie I

o dOResI2JJ "Unknown

+ I boos ter tlhot

3842

64I2

9J

40.94S.26.44.31.12.1

100.0

Number of reported ca~es of paralyticpoliomvelitiR, by month of onRet of symptoms

Dominican Republic: 1 Januarv - 30 September 1980

The 93 reported ca!'le!'l repre8ent an incidence rateof 2.S) per 100,000 population. of the 93 person.!'!, 'idied from CaUl'le8 attributable to poliomvelitiR, whichis equivalent to a case fatality rate of 'i.37%.

Source: Divi!'lion of Epidemiology, State Secretariat ofPublic Health and Welfare, Dominican Republic.

So far, all the information provided iCl baRed onClinical diagnoses of paralytic poliomyelitic:. Forpurpose!; of laboratory confirmation, qtool e:pecimenlland ma~ched blood Rpecimeo!'l from the patiente: were sentto the Center for Di.~~ealle Control, Atlanta, Georgia.The results are not vet available.

MonthA Number %

January 1 1.1FebruarY 1 1.1April I 1.1Hay 10 10.7June 18 19.4Jul y 28 30.1August 22 2J .6September 12 12.9

TOTAL 93 100.0

Three additional case<;poliomyelitis were ruled outDomingo Rehabilitation Center.

reportedSR lluch

..bv

para 1vt icthe San to

ThE" distribution of cases bv age group Ilhows that94.6% of them occurred in children under 2 years of age(Table 2). and 92.S% occurred in children who had notreceived the complete schedule of three dalles: ofvaccine (Table 3).

Tab 1e 2

Cold Chain

Developing Alternatives for theSolution of Cold Chain Problems

3Reference: HKWR 27 :427-430, 435-437, 1980.

Diqtribution of caseR of paralvticpoliomyelitiR by age group

Dominican Republic: 1 January - 30 September 1980

Age Group Number

Leltq than year 4S1-2 years 43J-4 Years 3S year!'! or more 2

TOTAL 93

%

48.446.2

3.22.2

100.0

The cold Chain is one of many concerns facing coun­tries in the Region in their efforts to expand immuniza­tion services. EPI Program Managers may find themselvesfaced not only with the lack of proper cold chain equip­ment but also \lith insufficient funds to remedy thedeficiencies. Consequently, countries must make maximumuse of already available resources in order to establishan adequate cold chain system.

Peru is one country which has made innovative useof locally available materials by developing a vaccinecold box from shipping containers. tn collaborationwith PAHO, Peru has produced a cold box for the trans­portation of vacc ines by recyc ling the shipping con­tainers in which measles vaccine is received from thesupplier. The containers for measles vaccine are usedbecause they afford the proper amount of polyurethaneinsulation.

7

Reported Cases of EPI Diseases in the AmericasNUMBER OF REPORTED CASES OF MEASLES. POLIOKYElITIS, TETANUS, DIPHTHERIA AND WHOOPING COUGH

FROM 1 JANUAllY THROUGH THE LAST PERIOD REPORTED IN 1980AND FOR THE COMPARABLE PERIOD IN 1979 BY COUNTRY,

DATE MEASLES POLIOKYELITIS TETANUS DIPHTHUIA WIIOOPING COUCHCOUllTll.Y OF LAST

REPORT 1980 1979 1980 1979 19BO 1979 1980 1979 1980 1979

ARGENTIIIA 19 Aor 1.096 1.287 " 1 ,I. " 11 1.1 7 466 5 325

IlAIWlAS 25 OCt. 458 1,505 - - 3 2 - - 15 -

IAUAOOS 4 OCt. 26 12 - - 10 6 10 12 - 2

BOLIVIA 23 Feb. 258 360 1 138 18 23 10 I. 233 131

BRAZIL 31 May 19,908 15,352 845 934 944 1,017 1,587 1,896 13,627 9,908

CAIlADA 6 Sep. 12,411 21,455 - 2 46 52 1.45b 1,353.. . ...CHILE 16 Aug. 2,603 17,131 - - 14 ... 181 241 680 239

COUllBIA 15 Jun. 3,769 10,529 53 309 288 . .. 162 95 ].664 5,838

COSTA I.ICI. 18 Oct. 930 5,411 - - 9 20 - - 803 199

CUM 13 SeD. 3,143 6,513 - 1 19 21 - - 81 125

DOKINlCA 26 Jul. - 177 1 - 2 1 1a ) b) - 1 -

DOMINICAN REP. 31 Mar. 3 132 1 411 93c ) 9c) 31 33 82 50 88 27

ECUADOR 2 Au•. 1,257 3,192 5 5 59 40 4 7 599 1,316

EL SAtVADOR 4 Oct. 1 458 9 761 7 1 57 91 - d) - 559 719

GRENADA 18 Oct. 53 2 - - - 2 1 - 2 6

GUATEMALA 16 Au•. 1,798 2,795 47 24 47 36 5 1 1,036 877

Gl1YAIIA Aug. a ) I23 448 126 ... .. . 9 2 1 4 . .. ...

BUTI 20 Seo. 143 253 4 - 101 56 6 5 413") 182

BOIIDl1IA8 27 SeD. 3,282 3,946 3 221 21b) 34 2 2 1,834 1,882

JAMAICA 16 Au•. 18 81 - - 7 9 4 6 8 33

IIEl[ICO 31 May 17 978 17 737 348 262 257 266 4 4 2.207 2,923

IIICAlAGlIA e) 156 - - 2 175.. . .. . .. . .. . ... ...pAJWolA

'" 1 ,., "" ," " 42· 426- - - -N.UGCAY

" <.n 476 792 7 II. 143 133 4 1 719 547

PlIU11 <.n. I. 017 ,. '17 94 41 178 123 131 81 2 240 6 994

SAINT LIlCIA11 0" " I. 1 5 1 1- - - -

SUlIlW!E ,,- 1- - - - - - - -TRD!IIloU) , TOBAGO

" <.n "I. 364 - - 19 22 - 1 9 28

U.8.~. 1 Nov. 13 095 12 588 8f ) 258) 60 59 4 58 1,419 1,164

UlUGCAY 31 Jul· 83 902 - 1 7 7 - - 126 148

VENEZlIllIA 11 Oct. 7,173 17,977 - 51 - 10 1 2,099 1,387...a) Source: CAREe SurveJ.Ilance Report.

September 1980.b) Data through 20 September.c) Source: Secretariat of Public Health

and Welfare, 30 September 1980.d) Data through 30 August.

e) Data not ava~lable for 1980.Data for 1979 through last epi­demiological period in October.

f) Six paralytic cases.g) Twenty-one paralytic cases.

- No cases

. .. Data not available

8

The converted container is shovn in Figures BandC. The internal dimensions of the container are 48 x40 x 34.5 cm, while the exterior measures 63.5 x 56.5 x52.5 C1D. The container has 10.16 cm. of polyurethaneinsulation and weighs 9 kilos.

The container has been shipped to CIMDER, the Re­gional Cold Chain Center in Cali, Colombia, for testingin order to determine its cold life and robustness.Preliminary tests carried out in Peru indicate the con­verted container may have an excellent cold life. Theresults of the CUiDER tests will be published in theEPI Newsletter as soon as they are available.

Figure C

Shipping conta1ner convertedinto cold box (interior view)

Figure A

Original mea­sles vaccineshipping con­tainer

Figure 8

Shipping con­tainer conver­ted into coldbox (exteriorview)

I

IIIllIlDrnII IIATIIIAl UP

t

The original container, before undergoing the con­version process, is shown in Figure A. It is convertedby recovering the interior and exterior with fiberglassand applying a rigid polyester resin. The lid of thecontainer is made of wood and is also covered withfiberglass. The 1 id is then attached by means of apiano-type hinge. Finally, handles are embedded intothe fiberglass and a padlock is attached.

n.~ EPI Hew.letter i. a periodie publieation prepared by the EltpandedProgrua on I_Wliution (EPI) of the Pan AlIII!rican Health OrCanintion, bClonalOffice for the America. of WHO. Its purpose is to facilitate che ell;ehang- ofideal and infonution toncerninc illllllWliution prograllls in the bgion in order toprolllote gTl~ .. tf!r knowledge of the problelU f.ced and their poslible lolutions.

iehrenee. to tOlllmercial products and the publitation of .igned articleain this new.letter do not con.titute endorsement by PANO/WHO, nor do the)' nece.­sarily repreaent the policy of the Oraaniution.

Editor; Dr. C. A. de Qu.drolA.ai.tant [ditor; Mr. P. CarraacoEditorial Assistant; Ma. K. Fitch

Contributor. to this i.aue:

Ma. H. Ander.on, PARODr. P. Cavalit, PARODr. C. H. Tigre, PAROMr. A. Uribe, PARD

Expanded Program on Immuniza tionPan American Health Organization525 Twenty-third St., N.W.Washington, D.C. 20037U.S.A.