unasur’s role in the vaccination against pandemic...

IMMUNIZE AND PROTECT YOUR FAMILY

Volume XXXII, Number 4 August 2010

In thIs Issue:

1 UNASUR’sRoleintheVaccinationAgainstPandemicInfluenza

1 PolioinTajikistan:AReminderoftheRiskofImportationstoPolio-freeRegions

3 WHODirector-GeneralStatementFollowingthe9thMeetingoftheEmergencyCommittee

3 Haiti:VaccinationCampaignFollowingtheEarthquake

5 AdvancesinCervicalCancerPreventioninLatinAmerica

5 What’sNewAboutVaccineSurveillance7 QuestionsandAnswersAboutVaccination8 HistoryoftheEPIinColombia

See TAJIKISTAN page 6

Polio in Tajikistan: A Reminder of the Risk of Importations to Polio-free RegionsA marked increase in the reportednumber of acute flaccid paralysis(AFP) cases last April led Tajikistanto confirm a polio outbreak due towild poliovirus type 1. By the endofAugust,a totalof456 laboratory-confirmed cases of wild poliovirustype 1, including 20 deaths (Figure1),havebeenconfirmed.Mostofthecases in Tajikistan have occurred intheSouthwesternpartofthecountry(Figure 2). Of the confirmed cases,313 (69%) are in children aged <5yearsand90(19%)inchildrenaged6-14years.Thelastcasehadparaly-sisonseton4July.ThevirusseemstohavebeenimportedfromIndia.

The outbreak has spread to neigh-boringcountries.Sincethebeginningof2010, theRussianFederationhasreported 12 confirmed polio casesand Turkmenistan 3 cases. Kazakh-stan, Kyrgyzstan, and Uzbekistanhave strengthened surveillance, butnopoliocaseshavebeenconfirmed.

This is the first wild poliovirus im-portation into the European Regionof the World Health Organization(WHO) since it was certified poliofreein2002.ReportedOPV-3cover-agelevelsfromTajikistanhavebeen>85% since the late 1990s and thelastpoliocasesoccurredin1997.

Inresponseto theoutbreak,severalimmunization campaigns using themonovalent polio type 1 vaccinehavebeenimplementedinTajikistan(4 roundswithcoverage levels99%

UNASUR’s Role in the Vaccination Against Pandemic InfluenzaBackgroundTheUnionofSouthAmericanNations(UNASUR)wasfoundedon23May2008inthecityofBrasilia,Brazil,whereitsconstitutivetreatywassigned.UNASURisformedby12SouthAmericancountriesanditspurposeistoprovide,inaconsensualandparticipatorymanner,anopportunityforcountriestouniteonthecultural,social,economic,andpoliticallevels,followingtheEuropeanmodel.

TheSouthAmericanHealthCouncilorUNASURHealthwascreatedon16December2008toprovideanop-portunityforintegrationwithregardtohealth.UNASURHealth,has5technicalcommissions:(1)Epidemiologi-calshield,(2)Developmentofuniversalhealthsystems,(3)Universalaccesstodrugs,(4)Healthpromotionandactiononsocialdeterminants,and(5)Developmentandmanagementofhumanresourcesinhealth.

Influenza A(H1N1) 2009 PandemicAtameetingoftheSouthAmericanHealthCouncilon8August2009,theUNASURcountries,inlightofthethreatgeneratedbythefirstinfluenzapandemicofthe21stcentury,consideredthefollowingfacts:• Theinfluenzapandemicconstitutedapublichealthchallenge.

Extraordinary Meeting of the South American Health Council on 8 August 2009 in Quito, Ecuador.

2 IMMUNIZATION NEWSLETTER Volume XXXII, Number 4 August 2010 PAN AMERICAN HEALTH ORGANIZATION

• Theglobalcommunityhadtofounditsworkontheprinciplesofsolidarity,justice,andeq-uitytoprovideaccesstovaccines,drugs,andstrategic supplies in order to control H1N1influenza.

• The production, availability, and access tovaccines,drugs,andstrategicsupplieswasse-verelylimitedatRegionallevel.

In view of the above three facts, the UNASURcountriesresolvedtotakethefollowingactions:1.Ratifytheconceptofpublichealthsupremacy

aboveeconomicandcommercialinterests.2.Strengthen the collective efforts of member

countries,resultinginanabilitytobringcon-creteresponses.

3.Declareasglobalpublicgoodsall thedrugs,vaccines,andequipmentthatarerequiredtorespondtothepandemic.

4.Ask the World Health Organization (WHO)to urge developed nations to fulfill the jointpriority protocol to guarantee equitable andtimelyaccesstovaccinesbyallcountries.

5.Decidethatintellectualpropertyrightsshouldnot prevent Member States from adoptingmeasurestoprotectpublichealth.

6.DevelopastrategicplanforRegionalinnova-tion,development,andproductiontoguaran-teeaccesstobiologicals,drugs,andsupplies.

7.SupporttheRevolvingFundofthePanAmeri-canHealthOrganization(PAHO)asthestrate-gic mechanism for Regional negotiation andurgethatacquisitionfromRegionalproducersbeprioritized.

8.Decide that themain strategy for short-termaccesstopandemicinfluenzavaccineswillbebasedonjointnegotiationthroughthePAHORevolvingFund, inordertoguaranteetimelyand equitable access by vulnerable popula-tionsandprevent commercial interests fromtakingadvantageofthepanicanduncertaintycausedbythepandemic.

TheH1N1influenzavaccinesgeneratedgreatex-pectationsforthesocialandpoliticalagendaofcountries.MinistersofHealthofSouthAmericahaveparticipatedinthemonitoringofprocure-mentandvaccinedeliveryprocesses,andhavereceivedbriefingsfromPAHOontheH1N1situ-ation in the Americas. The UNASUR supportedPAHOduringnegotiationstoobtainbetterprice,quality, and claim conditions, strengtheningPAHO’sadvisoryroleandarticulationwithotheractorsinhealth.

UNASURcountrieshavealsoendorsedtheWHOandPAHOtechnicalrecommendationsforvacci-nationwithregardtothequalitycriteriaforvac-cinestobeacquiredandthedesignationofpri-oritygroupsforpandemicinfluenzavaccination.

Guayaquil Resolution, November 2009The South American Health Council met inNovember2009 to review advances in vaccineprocurementthroughthePAHORevolvingFund.Duringthemeeting,MembersStatesresolvedto:“Recognizethesuccessachievedintheprocure-mentofpandemicinfluenzavaccinethroughthePAHO Revolving Fund and underscore the im-portanceofcontinuingtopromotestrategiesforjoint negotiation for the procurement of drugsand strategic supplies of public health interestinorder to guarantee improvedquality, timeli-ness,andequitywhilerespectingtheprinciplesoflowerpriceandsingleprice.”

Furthermore,thecountriesagreedtoinitiatethevaccinationofprioritygroups,toimportvaccinesthrough diplomatic groups, to prepare masscommunicationguidelinessupportingtheprior-izationofvaccination,andtoshareinformationoneventssupposedlyattributabletovaccinationorimmunization(ESAVIs).

Based on this experience, UNASUR has pre-sentednewchallenges,suchasuniversalaccessto drugs and joint fight against illegal drugs, acontinentalplanagainstdengue,borderhealth,andtheprioritizationofresearchforagainstfor-gottendiseases.

ConclusionsThe threatof thepandemicbecameanoppor-tunityforintegrationandjointresponsebyUN-ASUR’s member countries. Pandemic influenzavaccinationwaspartofan integrated responsethat includedpharmaceuticalandnon-pharma-ceuticalmeasures.

Thepandemicalsomadeitpossibletoregulatethe industry and avoid unilateral marketing tocountries,whichcouldhaveendangeredvaccineaccess through undue influence on their avail-ability and cost, guarantee vaccine access at alowerpriceandasingleprice,andachieveeq-uityinaccess.Intheend,itservedasacatalystforfuturecooperationregardingnewchallengesinpublichealth.

Figure 1. Pandemic Influenza (H1N1) Vaccine Acquisition in Latin America and the Caribbean

Source:FCH/IM,PAHO(dataasofNovember2010).

Vaccine Source:• Revolving Fund-RF (PAHO)• WHO Donation• Direct Purchase (DP)• RF-PAHO and WHO Donation• DP and WHO Donation• Mixed Purchase

Approximately170 million doses

PAN AMERICAN HEALTH ORGANIZATION IMMUNIZATION NEWSLETTER Volume XXXII, Number 4 August 2010 3

tinuetocirculateforsomeyearstocome,takingonthebehaviorofaseasonalinfluenzavirus.

TheCommitteeagreedthattheglobalinfluenzasituationnolongerrepresentedanextraordinaryevent requiring immediate emergency actionsonaninternationalscale.Intheirview,thepub-lic health emergency of international concern,recommended following the emergence of theH1N1(2009)virus,shouldbeconsideredover.TheCommitteefurthernotedthatthetemporaryrecommendations adopted in response to thepublic health emergency of international con-cernwereterminated.

After extensive discussions, the Committeeunanimously advised the Director-General thattheworldwasnolongerexperiencinganinfluen-zapandemic,but thatsomecountriescontinueto experience significantH1N1 (2009) epidem-ics.Membersagreedthatwaitingforwinterdatafromthesouthernhemispherehadbeenneces-saryinordertomakesuchaglobalassessmentwithreasonableconfidence.

The Committee noted that the informationfromIndia,NewZealand,andthePacificIslandcountries was consistent with the expectationthat individual countries might experience sig-nificant levels of influenza associated with theH1N1(2009)virusinthefuture,andexpressedthe need for national authorities to continueto implement outbreak response measures in

TheEmergencyCommitteeoftheWorldHealthOrganization (WHO) held its ninth meeting byteleconferenceon10August2010.

TheEmergencyCommitteewasgivenanepide-miological overview and update of the globalH1N1 (2009) pandemic influenza situation bythe secretariat. Particular emphasis was placedontheepidemiologicalsituationinthesouthernhemisphere,wheremany countries are experi-encingtheirwinterinfluenzaseason.Theupdatealso covered certain countries reporting activepandemic influenza virus transmission. Rep-resentatives of the governments of Argentina,Australia, India,NewZealand,andSouthAfricadescribedthemostrecentdevelopmentsintheircountries. Particular attention was given to thesituationinsomecountries,includingIndiaandNewZealand,whicharecurrentlyexperiencingintense influenza epidemics largely caused bytheH1N1(2009)virus.

Whilenoting suchepidemicswith concern, theCommittee based its assessment on the globalsituation.Membersnotedclearindicationsthatinfluenza, worldwide, is transitioning towardsseasonalpatternsoftransmission.Inthemajor-ityofcountries,out-of-seasonoutbreaksarenolongerbeingobserved,andtheintensityofH1N1(2009)transmissionislowerthanthatreportedduring 2009 and early 2010. Members furthernotedthattheH1N1(2009)viruswilllikelycon-

those countries when such events occur. TheCommittee strongly emphasized the need forStates to maintain vigilant disease surveillanceandmonitoringfor influenzaoutbreaksandin-fluenza-likeillnessaswellasensuringtheavail-ability of necessarypublic health measures forpreventingandcontrollinginfluenza.Suchmea-suresincludethecontinueduseofH1N1(2009)pandemicorseasonalinfluenzavaccineswhereappropriateandavailable.TheCommitteenotedthattheuptakeofpandemicvaccineinsomePa-cific Island countries appeared sufficientlyhightoreducetheriskofoutbreaksintheseStates.

BasedontheadviceoftheEmergencyCommit-tee,andherownassessmentofthesituation,theDirector-Generaldeterminedthattheworldwasno longer inan influenzapandemicand there-foreterminatedthepublichealthemergencyofinternationalconcerninaccordancewiththeIn-ternationalHealthRegulations(2005).

In light of these determinations, the Director-General thanked themembersand theadvisorof the Emergency Committee for their diligentserviceandexpert advice,whichwereof greatimportancetointernationalpublichealth.

TheworkoftheEmergencyCommitteenowbe-ingended, thenames,affiliationsanddeclaredinterestsoftheCommitteemembersandadvisorwillbepublishedontheWHOwebsiteassoonaspossible.

Note:FormoreinformationonthemeetingsoftheEmer-gency Committee concerning Influenza Pandemic H1N12009andafulllistofitsmembersandadvisors,pleaseseehttp://www.who.int/ihr/ihr_ec/en/index.html.

WHO Director-General Statement Following the 9th Meeting of the Emergency Committee

Haiti: Vaccination Campaign Following the EarthquakeOn 12 January 2010, a 7.0-magnitude earth-quake killed an estimated 220,000 people anddevastated Haiti’s capital, Port-au-Prince, andsurroundingareas.Todate, thereare stillover1millionpeoplelivinginmorethan800tempo-rarysettlements.

In Haiti, the immunization program has beenhistoricallyweakandsomevaccine-preventablediseases (diphtheria, pertussis, tetanus, neona-tal tetanus) remain as public health concerns.Non-neonatal tetanus represented 2% of theinfectiouscausesofdeath,excludingtheneona-talperiod(2000data)andtheneonataltetanus(NNT)casesreportedbyHaitirepresentroughly

halfofall reportedNNTcases in theAmericas.The immunization schedule only includes thebasicExpandedProgramonImmunization(EPI)vaccines targeting childrenaged<1year:BCG,oralpoliovaccine(OPV),diphtheria-tetanus-per-tussis (DTP), measles, and, since 2008, rubellaas the measles-rubella combination vaccine(MR). Haiti is the only country in the WesternHemisphere that does not include hepatitis Band Haemophilus influenzae type b (Hib) vac-cines,orothervaccinesforpersonsagedover1yearinitsnationalimmunizationschedule.Since2000, reported coverage levels for DTP3 havefluctuated between 39-79%, with 68% cover-agereported for2009.The lastwildpoliocase

inHaitioccurredin1989andthelastoutbreakof vaccine-derived poliovirus in 2000-2001. Nomeasles cases have occurred since 2001. Vac-cination campaigns against polio and measleshavemaintainedbothdiseasesatbay.

National Post-Disaster Vaccination PlanSoonaftertheearthquake,theNationalImmuni-zationProgramdevelopedanationalpost-disas-tervaccinationplan,withsupportfromthePanAmericanHealthOrganization/WorldHealthOr-ganizationandUNICEF.Themainobjectivewastominimize theoccurrenceofvaccine-prevent-ablediseasesintheaftermathoftheearthquake.Theplanwasdividedinphases.

Phase 0.ImmediateprovisionofTd/TTvaccineandtetanusanti-toxintopersonsinjuredduring


theearthquakeandthoseundergoingemergen-cysurgeries,includingamputations.

Phase 1. Vaccination of displaced populationliving in temporary settlements in disaster-affectedmunicipalities.These includedPort-au-Prince,Pétionville,Croix-des-Bouquets,Delmas,Tabarre, Cité Soleil, and Carrefour in the Met-ropolitanArea;Léogâne,Gressier,Grand-Goâve,and Petit-Goâve in the Ouest Department; andJacmel in the Sud-Est Department. The targetpopulation and interventions included the fol-lowing:• Childrenaged6weeksto8months:DTP• Childrenaged9monthsto7years:DTP,MR

andvitaminAsupplements• Personsaged>8years:Td• Allchildrenaged>2years:albendazole

The rationale to include DTP/Td vaccinationwasthefactthatvaccinationactivitieswithDTPforchildrenandTd foradults in response toadiphtheriaoutbreakhadstartedinlate20091butwere interrupteddue to theearthquake.TherewassufficientstockofTdvaccineinthecountryatthetimeoftheearthquake.

Phase 2.ProvisionofasimilarpackageasthatforPhase1,butusingOPVinsteadofvitaminAsupplements, to all people aged <20 years liv-ingintheaffectedarearegardlessofthetypeofhousing. The vaccination campaign provides asecond dose of DTP/Td and MR for previouslyvaccinated persons and an additional opportu-nityforthosenotlivingintentsormissedduringphase1.

Strengthening Routine. The national post-disaster vaccination plan also includes intensi-fication of routine vaccination with all the EPIvaccines as an integrated health package forchildrenaged<5years,eveninareasnotdirect-lyaffectedbythedisaster,alongwithepidemio-logical surveillance inhealth institutionsandatcommunitylevel.

Implementation of Phase 1Phase 1 was implemented between Februaryand May 2010. The municipalities in the Met-ropolitanArea,CroixdesBouquets,Petit-GoâveandGrand-GoâvewerevaccinatedbetweenFeb-ruaryandApril;Ganthier,Gressier, JacmelandLéogânestartedvaccinating inApril.Thetargetpopulationwasinitiallyestimatedataround1.4millionpeople(around250,000childrenaged6weeksto7years)livinginover300sites,usingdatafromtheOfficefortheCoordinationofHu-manitarianAffairsoftheUnitedNations(OCHA).

1 DiphtheriaOutbreakinHaiti,2009.Immunization News-letter,VolumeXXXI,Number6(December2009).

Theestimatesbyagegroup,wereobtainedbyapplying the age distribution in the generalpopulation (1.86% for 6 weeks to 8 months;15.71%, 9 months to 7 years; and 82.43%, >8years). However, the population estimateschangedovertimeassettlementsappearedanddisappeared, some sites were counted twiceduringtheplanningstagebecauseofconfusionabout their names, and widespread relocationoccurred among the population following theearthquake.

Due to the high demand for vaccination, non-governmental organizations participated inphase 1, in coordination with Haiti’s EPI andthe municipality health bureaus. The Interna-tionalFederationoftheRedCross,MédecinsduMonde-Canada, the Spanish Marines, and theCuban brigades were the main foreign institu-tions involved in vaccination activities duringphase1. Injectionsafetymeasureswere imple-mentedfromtheonset,butwerealsoadjustedthrough enhanced training and supervision.Events supposedly attributable to vaccinationor immunization (ESAVIs), mostly local reac-tionsandfever,werereportedbythepopulationandhealthpersonnelworkingon the sites (nosevereESAVIswerereported).Several logisticalproblemshinderedtheimplementationofphase1.Health facilities, including somemunicipalityhealthbureaus,hadbeendestroyedorseverelydamaged.TheMinistryofHealthwasdamaged,which affected the ability of the system to dis-tributesalaries.Vehiclerentalswereaffectedbythe increased demand, leading to skyrocketing

prices.Wastedisposalwasanothermajorprob-lemduetodifficultiesinidentifyinganincinera-tionfacilitycharginganaffordableprice.

Calculatingcoveragewasnotpossibleduetotheinabilitytoestimatethetargetpopulation.Rapidcoverage monitoring (RCM) was implementedfollowing vaccination in the sites to provideinformation for conducting mop-up activities.However,RCMactivitiescouldnotbecompleteddue to logisticalchallenges.Overall,more than928,000 persons were vaccinated, 188,125 ofthemchildreninthe9month-7yearagegroup(Figure1).Basedontheavailabledata,coverageamongchildrenmaynothavereached80%.

ConclusionsImplementationofPhase1of thepost-disastervaccinationplaninHaititookalongtimetoim-plementandcoverageachievedduringvaccina-tionactivitieswasinsufficient.ThehighnumberofhumanitarianworkerstravelingtoHaitifromcountrieswheremeaslescontinuestooccurrep-resentsapersistentriskofmeaslesimportationgiven the existing pool of susceptible Haitians.In addition, diphtheria cases continue to occurinthecountry.Consequently,healthauthoritiesdecidedtohaltphase1ofthepost-disastervac-cinationplanandtoproceedwithphase2,whichwassupposedtobelaunchedinJuly.

Figure 1. Vaccine Doses Recorded by Age Group, Phase 1 Post-earthquake Vaccination, Affected Municipalities, Haiti, 2010

Source:Campaignbulletin;dataasof30May2010.

Croix-des-Bouquets44,658

Pétionville100,763

Ganthier12,116

Port-au-Prince219,423

Petit-Goâve61,083

Grand-Goâve4,213

Jacmel8,500

Léogâne48,249

Gressier20,704

Carrefour129,514

Delmas210,349

Tabarre34,103

Cité Soleil34,566

9 months to 7 years (DTP+MR)≥8 years (Td)

6 weeks to 8 months (DTP)

Legend:


Figure 1. Vaccine Doses Recorded by Age Group, Phase 1 Post-earthquake Vaccination, Affected Municipalities, Haiti, 2010

Advances in Cervical Cancer Prevention in Latin AmericaIthasbeenalmosttwoyearssincetheDirectingCouncil of the Pan American Health Organiza-tion (PAHO), a governance body composed ofMinistersofHealthfromtheAmericas,passedaresolutionurgingforthestrengtheningofcom-prehensivecervicalcancerpreventionprogramsinLatinAmericaandtheCaribbean.Theresolu-tionwaspassedaftertheMinistersreviewedandendorsedtheRegionalStrategyandPlanofAc-tionforCervicalCancerPreventionandControl outlining a seven-point action plan to improvethequality,coverage,andeffectivenessofcervi-cal cancer programs, including human papillo-mavirus(HPV)vaccineintroduction.

As a means to stimulate further implementa-tionof theRegional strategy,PAHO, theMinis-tryofHealthofPanama,andPATH1convenedameetingfrom2-3June2010inPanama.Over70healthprofessionalsfrom13LatinAmericancountries participated. The meeting provided

1 The Program for Appropriate Technology in Health(PATH) is an international non-governmental organiza-tion.

an opportunity to discuss recent scientific evi-dence regarding new screening technologiesand HPV vaccines, including regional evidencebeing generated by Latin American studies; todiscusstheimportanceofwomen’sandcommu-nityperspectivesandtheneedtoimprovepubliceducation to increase participation in preven-tion programs; to discuss country experiencesregarding introduction of new approaches andtechnologies such as the Panama experiencewith the introduction of the HPV vaccine andtheMexicoexperiencewithregardstointroduc-ingHPV testingandHPVvaccines; and toplancollaborative activities between countries withthe assistance of international organizations toimprove the effectiveness of their cervical can-cer prevention efforts. Representatives fromseveral international organizations, notably theUnion for International Cancer Control (UICC),theU.S.CentersforDiseaseControlandPreven-tion(CDC),andPATHwereonhandtopromoteinformationontheirvariousresourcesandtoolstoassistprogrammanagerswiththeirdecision-making. Of note are PATH’s Action Planner, anewweb-based interactive tool thatprovidesa

hands-on, step-by-step approach to designinga new or improving a comprehensive cervicalcancerprogram,andPAHO’sProVAC initiative,aprojecthelpingcountriestobuildcapacityforundertakingtheirowncost-effectivenessevalua-tionsfornewvaccineintroduction.

Themeetingparticipantscametothefollowingconclusions:• There is clear scientific evidence to support

the implementation of new technologies forcervicalcancerpreventionprograms;

• There is incredible interest, motivation, andenthusiasmonthepartofprogrammanagersintheMinistriesofHealthtoincorporatethesenewtechnologiesintotheircurrentprogramsandthemanagersareoftheopinionthatthe2008DirectingCouncilresolutionprovidesthepolitical impetus to move forward with suchchanges;and

• Thegreatestbarriertointroducingnewtech-nologiesintoprogramsisthecurrenthighcostofHPVvaccinesandtheHPVtest.

For more information, please see the PAHO webpageon the Latin American Sub-regional Meeting on CervicalCancer Prevention, available at: http://new.paho.org/hq/index.php?option=com_content&task=blogcategory&id=2300&Itemid=2318.

What’s New About New Vaccine SurveillanceWith the objective to globally strengthen andexpand surveillance for new and underutilizedvaccines,theWorldHealthOrganization(WHO)anditspartnersrecommendedin2007thatthestandardizingofsurveillancedatabeconsideredapriorityinthefollowingyears.Sincethen,vari-ousLatinAmericanandCaribbeansurveillancenetworksforrotavirusandinvasivebacterialdis-

easeshavebeenworkingonimprovingtheirsys-temsto(1)providequality informationfordis-ease burden estimation, (2) support evidence-baseddecision-makingonvaccineintroduction,(3) monitor circulation of specific serotypes/genotypes and changes in serotype/genotypedistributionandantimicrobialsusceptibility,and(4)evaluatevaccineimpactafteritsintroduction.

From 8-13 February 2010, the Pan AmericanHealthOrganization (PAHO)convenedameet-ing inWashington,D.C., torevisethemostrel-evant rotavirus and bacterial pneumonia andmeningitis surveillance variables applicable tochildren aged under five years and develop astandardized guide on variables to help coun-triesbetterinterprettheirsurveillancedata.

The result of the meeting was the production,andsubsequentpublication in July,of thebro-chure Nuevas vacunas: variables para la vigi-


Gorniy Badakhshan

Rayons of Republican Suberdination

Leninabad

betweenMayandJune2010).Campaignshavealso been conducted or will be conducted inSeptember in neighboring Kazakhstan, Kyrgyz-stan,Turkmenistan,andUzbekistan.TheRussianFederationhasinvestigatedcontactsandimple-mentedcatch-upvaccinationinareasaroundtheconfirmedcases.

WHO has maintained its recommendation nottoimposerestrictionstotheinternationalmove-ment of persons. However, it is important thatinternationaltravelerstoandfrompolio-affectedareasareadequatelyimmunizedagainstpolio.

CountriesoftheAmericasarealertedoftheriskofpolioimportations.Asillustratedbythecasesinpreviouslypolio-freecountriesinCentralAsia,while wild poliovirus continues to circulate insome areas, importations and outbreaks canoccur. The last case of wild polio occurred inthe Americas in Peru in 1991. To maintain theRegionfreeofwildpoliovirus,countriesareen-couragedtoassesstheirriskofanoutbreakfromimportations by analyzing their polio vaccinecoveragebymunicipalityandthecapacityofthesurveillancesystemtodetectanimportationinatimelymanner.Countriesnotreachingthemini-mumof1AFPcaseper100,000childrenaged<15yearsareencouragedtoconductactivecasesearchesintheirmainhospitals.

For more information: (1) Global Polio Eradication Ini-tiative (http://www.polioeradication.org/) and (2) WHOEpidemiological Brief 7: Polio outbreak in the EuropeanRegion and country responses, in English (http://www.euro.who.int/__data/assets/pdf_file/0011/121799/WHO_EPI_Brief_10sep_2010e.pdf).

TAJIKISTAN from page 1Figure 1. Laboratory Confirmed Polio Cases by Date of Paralysis Onset,

Tajikistan, 2010

Source: WeeklyAFPreportingtoWHOEuropeanRegion;dataasof18November2010.

Figure 2. Distribution of AFP and Laboratory-confirmed Polio Cases by District,* Tajikistan, 2010

Source: WeeklyAFPreportingtoWHOEuropeanRegion;dataasof25November2010.

SIARound 1mOPV1(99.4%)

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lancia centinela de rotavirus y meningitis y neu-monías bacterianas(availableinSpanishonly),whichincludesselectedessentialvariablestoas-sistwithdatacollectionregardingrotavirusandbacterialpneumoniaandmeningitisathospitalandnationallevels.

The variables that should figure on each pa-tient’s investigation form are described in the

brochure as either mandatory, recommended,oroptional,andinstructionsaregivenonhowtocorrectlycompletetheinvestigationform.

PAHOhasalsorecentlydevelopedanewweb-basedsoftware,VINUVA1,whichallowssentinelhospitalsand/or countriesof theAmericanRe-

1 VigilanciadeNuevasVacunas/NewVaccineSurveillance.

gion to capture, store, and report aggregatedsurveillancedatadirectlyfromthecountryleveltotheregionallevel.Thesoftwarewillallowdi-rectandsystematicdatareporting.Thiswillre-sult in amoreefficient systemandbetterdataquality.ThetoolwillbecomeavailableforusebycountriesstartinginMarch2011.


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es.T

heim

mun

osup

pres

sive

effe

cts

ofc

ortic

oste

roid

trea

tmen

tvar

y,b

utm

any

clini

cians

con

sider

a

dose

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ivale

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kgo

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eigh

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ato

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nefo

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ew

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cient

lyim

mun

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essiv

eto

rai

sec

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rna

bout

the

safe

tyo

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cinat

ion

with

live

viru

sva

ccin

es(e

.g.,

MM

R,v

arice

lla,L

AIV,

yel

low

feve

r).P

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dw

ait

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fter

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ient

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roid

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activ

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om-

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ched

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ough

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resp

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to

thes

eva

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ayb

esu

bopt

imal

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houl

dyo

uad

min

ister

vacc

ine

toa

per

son

who

ista

king

ant

ibio

tics?

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reat

men

twith

ant

ibio

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snot

av

alid

reas

onto

def

erv

accin

atio

n.If

th

ech

ildo

radu

ltis

othe

rwise

wel

l,or

has

onl

ya

min

oril

lnes

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ccin

es

shou

ldb

ead

min

ister

ed.B

utif

the

pers

onh

asa

mod

erat

eor

seve

rea

cute

illn

ess(

rega

rdle

sso

fant

ibio

ticu

se)o

nesh

ould

def

erva

ccin

atio

nun

tilth

epe

rson

’sco

nditi

onh

asim

prov

ed.

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oder

ate

ors

ever

eac

ute

illnes

s”is

ap

reca

utio

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rad

min

ister

ing

any

vacc

ine.

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ilda

cute

illn

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e.g.

,dia

rrhe

aor

mild

upp

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spira

tory

tra

ctin

fect

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with

or

with

outf

ever

isn

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hec

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vac

cinat

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som

eone

with

mod

erat

eor

sev

ere

illnes

sis

that

afe

ver

follo

win

gth

eva

ccin

eco

uld

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plica

tem

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emen

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tilln

ess

(that

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uld

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ifficu

ltto

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erm

ine

ifth

efe

ver

was

from

the

vacc

ine

or

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toth

eco

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rent

illn

ess)

.In

decid

ing

whe

ther

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accin

ate

apa

tient

w

ithm

oder

ate

ors

ever

eilln

ess,

the

clini

cian

need

sto

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erm

ine

iffo

rgoi

ngva

ccin

atio

nw

illin

crea

seth

epa

tient

’sris

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vacc

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prev

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ases

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case

ifth

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turn

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atio

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me

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form

ats(

audi

o/vi

deo)

,go

toth

eIm

mun

izat

ion

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nCo

aliti

on’s

web

site

at

ww

w.im

mun

ize.

org/

vis.

Adap

ted

from

http

://w

ww

.imm

uniz

e.or

g/as

kexp

erts

/exp

erts

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eral

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on

12N

o-ve

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than

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nCo

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eU.

S.C

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Pre

vent

ion.

Add

ition

al“

Ask

the

Expe

rts”

Q&A

sca

nbe

con

sulte

don

line

ath

ttp://

ww

w.im

mun

ize.

org/

aske

xper

ts.

Vacc

inat

ion Q

uest

ions

Mos

t Com

mon

ly As

ked b

y Hea

lthca

re Pr

ofes

siona

lssa

fety

oft

hese

vac

cines

inch

ildre

nw

ithse

vere

egg

alle

rgy.

Q:W

hata

ret

hes

pecia

lrec

omm

enda

tions

for

adm

inist

erin

gin

tra-

mus

cula

rinj

ectio

nsin

peo

ple

with

clo

tting

diso

rder

s?A:

IMin

ject

ions

shou

ldb

esc

hedu

led

shor

tlya

ftera

ntih

emop

hilia

ther

apy

orp

riort

oa

dose

ofa

ntico

agul

ant.

Forb

oth

IMa

ndS

C(s

ubcu

tane

ous)

in

ject

ions

,afi

nen

eedl

e(2

3ga

uge

ors

mal

ler)

sho

uld

beu

sed

and

firm

pr

essu

re(

subc

utan

eous

)ap

plie

dto

the

site

,w

ithou

tru

bbin

g,f

ora

tle

ast2

min

utes

.Pro

vider

ssh

ould

not

adm

inist

era

vac

cine

bya

rou

te

that

isn

ota

ppro

ved

fort

hatp

artic

ular

vac

cine

(e.g

.,ad

min

istra

tion

ofIM

va

ccin

esb

yth

eSC

rout

e).

Adm

inis

terin

g Va

ccin

esQ

:Isi

tnec

essa

ryto

wea

rglo

vesw

hen

we

adm

inist

erv

accin

atio

ns?

A:N

o.O

ccup

atio

nalS

afet

yand

Hea

lthA

dmin

istra

tion

(OSH

A)re

gula

tions

do

not

requ

ireh

ealth

care

per

sonn

elto

wea

rglo

vesw

hen

adm

inist

erin

gva

ccin

atio

ns,u

nles

sth

ehe

alth

care

wor

keri

slik

ely

toc

ome

into

con

tact

w

ithp

oten

tially

infe

ctio

usb

ody

fluid

sor

has

an

open

lesio

non

her

or

hish

and

Ifa

heal

thca

rew

orke

rch

oose

sto

wea

rgl

oves

,he

ors

hem

ustc

hang

eth

emb

etw

een

each

pat

ient

enc

ount

er.

Q:A

rev

accin

edi

luen

tsin

terc

hang

eabl

e?A:

Asa

gen

eral

rule

vac

cine

dilu

ents

are

noti

nter

chan

geab

le.

Q:W

hen

ava

ccin

evia

lis

new

and

the

cap

has

just

been

rem

oved

,is

the

rubb

erst

oppe

rste

rile,

ors

houl

dit

becl

eans

edw

itha

lcoho

lbef

ore

inse

rting

the

need

le?

A:T

heru

bber

stop

peri

snot

ster

ile.W

hen

you

rem

ove

the

prot

ectiv

eca

pfro

ma

vac

cine

ord

iluen

tvia

l,yo

ush

ould

alw

aysc

lean

the

stopp

erw

ith

ana

lcoho

lwip

e.

Q:I

sito

kay

tod

raw

up

vacc

ines

att

heb

egin

ning

oft

hesh

ift?I

fiti

sn’t,

ho

wm

uch

ina

dvan

ceca

nth

isbe

don

e?A:

PAH

Od

iscou

rage

sth

epr

actic

eof

pre

fillin

gva

ccin

ein

tos

yrin

ges,

prim

arily

bec

ause

of

the

incr

ease

dpo

ssib

ility

ofa

dmin

istra

tion

and

dosin

ger

rors

.Ano

ther

rea

son

tod

iscou

rage

the

prac

tice

ing

ener

alis

th

atso

me

vacc

ines

hav

ea

very

lim

ited

shel

flife

afte

rrec

onsti

tutio

n.

Q:I

sitn

eces

sary

toa

spira

teb

efor

eva

ccin

atin

g?A:

No.

PAH

Od

oesn

otre

com

men

das

pira

ting

(pul

ling

back

on

the

syrin

ge

plun

gero

nce

the

need

leis

inth

ear

mb

efor

ein

ject

ing,

tos

eeif

you

get

bl

ood

retu

rn)

whe

nad

min

ister

ing

vacc

ines

.No

data

exis

tto

justi

fyth

ene

edfo

rth

ispr

actic

e.IM

inje

ctio

nsa

ren

otg

iven

ina

reas

whe

rela

rge

vess

els

are

pres

ent.

Give

nth

esiz

eof

the

need

lea

ndth

ean

gle

atw

hich

yo

uin

ject

the

vacc

ine,

itw

ould

be

very

diffi

cult

toa

dmin

ister

the

vacc

ine

intra

veno

usly

.Q

:Ifa

dos

eof

vac

cine

isgi

ven

byth

ew

rong

rout

e(IM

inste

ado

fSC

or

vice

vers

a),d

oesi

tnee

dto

be

repe

ated

?A:

Alth

ough

vacc

ines

shou

lda

lway

sbe

give

nby

the

rout

ere

com

men

ded

byth

em

anuf

actu

rer,

ifa

vacc

ine

isin

adve

rtent

lyg

iven

byth

ew

rong

ro

ute,

PAH

Ore

com

men

dsth

atit

be

coun

ted

asva

lidw

ithtw

oex

cept

ions

:He

patit

isB

orra

bies

vacc

ine

give

nby

any

rout

eot

hert

han

IMsh

ould

not

be

coun

ted

asv

alid

and

shou

ldb

ere

peat

ed.

Q:W

hatl

engt

hof

nee

dle

shou

ldb

eus

edto

give

infa

ntsI

Min

ject

ions

?A:

PAH

Or

ecom

men

dst

hat

a5/

8”n

eedl

ebe

use

dto

adm

inist

erI

M

inje

ctio

nsin

an

ewbo

rno

rpre

mat

ure

infa

nto

nly

ifth

esk

inis

stre

tche

d

Sche

dulin

g Va

ccin

atio

nsQ

:Why

are

vacc

ines

gen

eral

lyn

otg

iven

toin

fant

sund

er6

wee

kso

fage

A:M

ainl

ybe

caus

elit

tlesa

fety

ore

ffica

cyd

ata

exist

on

dose

sgive

nbe

fore

6

wee

kso

fage

,and

the

vacc

ines

are

n’tl

icens

edfo

rthi

suse

.The

dat

ath

at

exist

sugg

estt

hatt

here

spon

seto

dos

esg

iven

befo

re6

wee

ksis

poo

r;th

ere

spon

seto

hep

atiti

sBa

ndB

CGv

accin

esis

the

exce

ptio

n.

Q:T

hen

umbe

rofi

njec

tions

reco

mm

ende

dto

be

give

nat

asi

ngle

offi

ce

visit

isin

crea

sing,

and

we

are

runn

ing

outo

finj

ectio

nsit

es.S

houl

dw

ede

ferc

erta

inv

accin

es?

A:W

estr

ongl

yre

com

men

dth

aty

oud

ono

tdef

era

nyr

ecom

men

ded

vacc

ines

.Thi

sw

ould

be

am

issed

opp

ortu

nity

.No

uppe

rlim

itha

sbe

en

esta

blish

edre

gard

ing

the

num

bero

fvac

cines

that

can

be

adm

inist

ered

in

one

visi

t.W

hen

givin

gse

vera

linj

ectio

nsa

ta

singl

evis

it,s

epar

ate

2in

tram

uscu

lar

(IM)

vacc

ines

by

atle

ast1

inch

(2.

5cm

)in

the

body

of

the

mus

cleto

red

uce

the

likel

ihoo

dof

loca

lrea

ctio

nso

verla

ppin

g.

Here

isa

link

toa

colle

ctio

nof

illu

strat

ions

(i.e

.,“s

item

aps”

)tha

tsho

ws

how

one

can

adm

inist

era

llin

dica

ted

dose

sto

chi

ldre

n:w

ww

.cdc.g

ov/

vacc

ines

/pub

s/pi

nkbo

ok/d

ownl

oads

/app

endi

ces/

D/sit

e-m

ap.p

df.11

If

live

pare

nter

al(

inje

cted

)va

ccin

es(

MM

Ran

d/or

yel

low

feve

r)a

ndli

ve

atte

nuat

edin

fluen

zav

accin

e(L

AIV)

are

not

adm

inist

ered

dur

ing

the

sam

evis

it,th

eysh

ould

be

sepa

rate

dby

4w

eeks

orm

ore.

Q:

IfI

have

to

give

mor

eth

an1

inje

ctio

nin

am

uscle

,are

cer

tain

va

ccin

esb

estg

iven

toge

ther

?A:

Sin

ceD

TPa

ndp

neum

ococ

calc

onju

gate

are

the

vacc

ines

mos

tlik

ely

to

caus

ea

loca

lrea

ctio

n,it

’spr

actic

alto

adm

inist

erth

emin

sepa

rate

lim

bs

(ifp

ossib

le),

soth

ere

isno

con

fusio

nab

outw

hich

vac

cine

caus

edth

ere

actio

n.

Q:W

hati

smea

ntb

y“m

inim

umin

terv

als”

bet

wee

nva

ccin

edo

ses?

A:V

accin

atio

nsc

hedu

les

are

gene

rally

det

erm

ined

by

clini

cal

trial

s,us

ually

prio

rto

lice

nsur

eof

the

vac

cine.

The

spa

cing

ofd

oses

int

he

clini

calt

rialu

sual

lyb

ecom

esth

ere

com

men

ded

sche

dule

.A“

min

imum

in

terv

al”

issh

orte

rth

anth

ere

com

men

ded

inte

rval

,and

isth

esh

orte

sttim

ebe

twee

ntw

odo

ses

ofa

vac

cine

serie

sin

whi

cha

nad

equa

te

resp

onse

toth

ese

cond

dos

eca

nbe

exp

ecte

d.

Q:I

sitn

eces

sary

tost

arta

vacc

ine

serie

sove

rifa

pat

ient

doe

sn’t

com

eba

ckfo

rad

ose

atth

ere

com

men

ded

time,

eve

nif

ther

e’sb

een

aye

ar

orm

ore

dela

y?A:

For

rou

tinel

yad

min

ister

edv

accin

es,

ther

eis

nov

accin

ese

ries

that

nee

dst

obe

res

tarte

dbe

caus

eof

an

inte

rval

tha

tis

long

ert

han

reco

mm

ende

d.I

nce

rtain

circ

umsta

nces

,or

alt

ypho

idv

accin

e(w

hich

is

som

etim

esg

iven

fori

nter

natio

nalt

rave

l)ne

eds

tob

ere

starte

dif

the

vacc

ine

serie

sisn

’tco

mpl

eted

with

inth

ere

com

men

ded

time

fram

e.

Prec

autio

ns a

nd C

ontr

aind

icat

ions

Q:F

orw

hich

vac

cines

isa

neg

gal

lerg

ya

cont

rain

dica

tion?

Wha

tabo

ut

MM

Rva

ccin

e?A:

Influ

enza

and

yel

low

fev

erv

accin

esa

ret

heo

nly

vacc

ines

tha

tar

eco

ntra

indi

cate

dfo

rpeo

ple

who

hav

ea

histo

ryo

fase

vere

(ana

phyl

actic

)al

lerg

yto

egg

s.Al

lerg

yto

egg

sisn

olo

nger

cons

ider

eda

cont

rain

dica

tion

forg

iving

MM

Rva

ccin

e.T

houg

hm

easle

sand

mum

psva

ccin

esa

reg

row

nin

chi

cke

mbr

yot

issue

cul

ture

,sev

eral

stu

dies

hav

edo

cum

ente

dth

e1

Info

rmat

ion

isal

soa

vaila

ble

from

pre

vious

issu

eso

fthe

Imm

uniza

tion

New

slette

r:Ho

w

toa

dmin

ister

Intra

mus

cula

r(IM

)Inj

ectio

ns(A

pril

2003

)(av

aila

ble

ath

ttp://

ww

w.p

aho.

org/

engl

ish/a

d/fc

h/im

/sne

2502

.pdf

)an

dHo

wto

Adm

inist

erS

ubcu

tane

ous

(SC)

Inje

c-tio

ns(J

une

2003

)(av

aila

ble

ath

ttp://

ww

w.p

aho.

org/

engl

ish/a

d/fc

h/im

/sne

2503

.pdf

).


The Immunization Newsletterispublishedeverytwomonths,inEnglish,Spanish,andFrenchbytheImmunizationUnitofthePanAmericanHealthOrganization(PAHO),RegionalOfficefortheAmericasoftheWorldHealthOrganization(WHO).ThepurposeoftheImmunization NewsletteristofacilitatetheexchangeofideasandinformationconcerningimmunizationprogramsintheRegion,inordertopromotegreaterknowledgeoftheproblemsfacedandpossiblesolutionstothoseproblems.

ReferencestocommercialproductsandthepublicationofsignedarticlesinthisNewsletterdonotconstituteendorsementbyPAHO/WHO,nordotheynecessarilyrepresentthepolicyoftheOrganization.

ISSN1814-6244VolumeXXXII,Number4•August2010

Editor:JonAndrusAssociateEditors:BéatriceCarpanoandCarolinaDanovaro

Immunization Unit525Twenty-thirdStreet,N.W.Washington,D.C.20037U.S.A.http://www.paho.org/immunization

La Cruzada Interminable por la Niñez Colombiana

MINISTERIO DE LA PROTECCIÓN SOCIALORGANIZACIÓN PANAMERICANA DE LA SALUD

HISTORIA DEL PROGRAMA AMPLIADO DEINMUNIZACIONES (PAI) EN COLOMBIA 1979-2009

History of the Expanded Program on Immunization in ColombiaOn15June2010,Cruzada Interminable por la Niñez Colombiana (Ceaseless Crusade for theColombian Children) was launched in Bogotá,Colombia.ThebookretracesthethirtyyearsoftheExpandedProgramonImmunization(EPI)inColombia.ItwasintroducedtothepublicinthepresenceofDr.DiegoPalacioBetancourt,Min-isterofSocialProtection,CarlosIgnacioCuervoValencia,Vice-ministerofHealthandWellbeing,Dr.JuanGonzaloLopezCasas,Director,NationalInstituteofHealth,andDr.JorgeCastilla,repre-sentingthePanAmericanHealthOrganization.

Inhisremarks,Dr.Palaciostatedthattheobjec-tive of Cruzada Interminable por la Niñez Co-lombianawas to record thehistoryof theEPI,rememberingitsmaincontributorsandrecallingitsmostsalientsuccesses.Althoughitisnotex-haustive,thebook’sintentistoprovideareflec-tionon immunization:aquietandmodest, yethistoric,experiencethatchangedthelifeofCo-lombiansociety.Readingthroughitspages,onelearnsaboutsmallpoxeradicationandpoliomy-

elitiseradicationand,closertoourtime,theimminentverificationofmeasles, rubella, and congenitalrubella syndrome elimination.Dr.Palacioalsonoted thatmanychallengesremain,amongothersreaching homogenous coverageinallmunicipalitiesinthecountryand the sustainable introductionofnewvaccines.Yet,theEPIcancountonanextraordinarypowerto keep on advancing: its dedi-cated workforce that considerstheir work for the EPI as a duty,evena lifemissionanda raison-d’être.Today,theEPIfunctionsasahighlyparticipativeprocessthatprovideseachhealthcareworkerwiththeopportunitytocontributetotheprogramwithsuggestions,initiatives,andideas.Thebookisthereforeaheartfelthomagetoallthewomenandmenwhohaveworkedand

areworkingfortheEPI.

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