Vaccination coverage in Mhala and Elim in 1990--a health systems approach.

This paper assesses the implementation of the 1986 Gazankulu policy on immunisation in 2 of the homeland's 6 health wards, Mhala and Elim. Vaccination coverage was estimated using the cluster sampling technique recommended by the Expanded Programme on Immunisation of the World Health Organisation. Vaccination coverage of children aged 12-23 months who have received eight valid doses (as stipulated in the programme) is estimated at 25% in Mhala and 53% in Elim (P < 0.001). While both figures can be substantially improved, the analysis concentrates on factors that help explain the differences between 2 districts that fall under the same central administration. As well as demographic differences, key factors include the presence of community-based health facilities and availability of staff (including programme leaders). The need for regional planners to have detailed and comprehensive knowledge of the health system at district level, and to make allowance for this, is put forward as vital to effective health planning. The failure of the Gazankulu policy to attain its objectives also reflects the often unrecognised consequences of the fragmentation of health services.     

Vaccine cold-chain status in the Elim health ward of Gazankulu

The vaccine cold-chain is a fundamental component of any immunisation programme. This study used chemical-based temperature indicators to monitor the cold-chain constantly in the Elim Hospital health ward of Gazankulu. It was found that the cold-chain was adequately maintained at the hospital, but that as vaccine travelled towards the periphery severe breaks in the cold-chain occurred. Eighteen per cent of vaccines at the Elim Hospital store and up to 90% at the periphery were potentially exposed to temperatures high enough and for a sufficient length of time to have affected their potency. More emphasis needs to be placed on maintaining the cold-chain if we are to reach to EPI's goal of immunisation for all children by the year 1990.     

Alexandra township--is immunisation adequate?

In this study we assessed immunisation coverage and identified some of the factors that are predictive of non-immunisation in Alexandra township. A cohort of 348 babies delivered through the Alexandra clinic system in March and April 1986 were followed up for 4-5 months to see whether they returned for the first DPT and poliomyelitis immunisation. Two hundred and twenty-eight of the eligible babies (66%) received the first DPT and polio immunisation. Of the 120 who were not immunised, 54 (16% of the total) were not traced, 46 (13%) were transferred to another area and 20 (6%) were traced defaulters. Babies born to mothers who had not attended antenatal clinics and who lived outside Alexandra had children with significantly lower immunisation coverage than those born to other mothers. the sex of the baby, maternal age, previous sibling death, maternal parity and paternal support were not associated with any difference in immunisation coverage. In this paper some of the reasons for the low immunisation coverage are discussed and suggestions as to how this can be improved are given.     

Preparing oral hydration solution with a cup method

In a survey of 195 homes in four villages in the Mhala area of Gazankulu, 90% of women caring for under-5 children were able to make an oral hydration solution (OHS). Seventy-five per cent of these women indicated that they would use an OHS as first-line management for diarrhoea. Seventy-nine per cent (139) of these solutions were prepared using a cup method and 13% (23) using a litre-bottle method. A biochemically ideal sodium concentration was found in 31% (43) of solutions made using the cup method and in 17% (5) of those made using the litre method. The solutions are further analysed. The appropriateness of the cup and litre measures for home-made OHS in these circumstances is studied and discussed. The cup method is considered to have advantages because utensils and ingredients for this method are more readily available in these rural homes. Dual messages given to this community may be responsible for the apparent confusion about making OHS, and it is advocated that health education about OHS should where possible be standardised.     

Is childhood immunisation associated with atopic disease from age 7 to 32?years?

BACKGROUND: There is ongoing conjecture over whether childhood immunisation leads to an increased risk of developing atopic diseases. OBJECTIVE: To examine associations between childhood immunisation and the risk of atopic disease. Method: Immunisation histories of 8443 Tasmanian children born in 1961 obtained from school medical records were linked to the Tasmanian Asthma Study. Associations between immunisation status and atopic diseases were examined while adjusting for possible confounders using multiple logistic regression. RESULTS: Diphtheria immunisation was weakly associated with an increased risk of asthma by age 7 years (odds ratio (OR) 1.3, 95% confidence interval (CI) 1.1 to 1.7), but there was no evidence of any association for four other vaccinations studied. An increased risk of eczema by age 7 years was associated with immunisation against diphtheria (OR 1.5, 95% CI 1.1 to 2.1), tetanus (OR 1.5, 95% CI, 1.1 to 2.0), pertussis (OR 1.5, 95% CI 1.1 to 1.9) and polio (OR 1.4, 95% CI 1.0 to 1.9) but not small pox. Similar but slightly weaker patterns of association were observed between the risk of food allergies and immunisation against diphtheria (OR 1.5, 95% CI 1.0 to 2.1), pertussis (OR 1.4, 95% CI 1.1 to 1.9), polio (OR 1.4, 95% CI 1.00 to 2.1) and tetanus (OR 1.30 95% CI 0.99 to 1.70), but not with small pox. There was no evidence of associations between immunisation history and hay fever, or incidence of later-onset atopic outcomes. CONCLUSIONS: The few effects seen in this study are small and age-dependent, and nearly all our findings support numerous previous studies of no effect of vaccines on asthma. Based on these findings, the fear of their child developing atopic disease should not deter parents from immunising their children, especially when weighed against the benefits.     

The Use of Executed Prisoners as a Source of Organ Transplants in China Must Stop

Internationally accepted ethical standards are unequivocal in their prohibition of the use of organs recovered from executed prisoners: yet this practice continues in China despite indications that Ministry of Health officials intend to end this abhorrent practice. Recently published articles on this topic emphasize the medical complications that result from liver transplantation from executed ‘donors’ but scant attention is given to the source of the organs, raising concern that the transplant community may be coming inured to unacceptable practice. Strategies to influence positive change in organ donation practice in China by the international transplant community are discussed. They include an absolutist policy whereby no clinical data from China is deemed acceptable until unacceptable donation practices end, and an incremental policy whereby clinical data is carefully evaluated for acceptability. The relative advantages and drawbacks of these strategies are discussed together with some practical suggestions for response available to individuals and the transplant community.     

Susceptibility to poliomyelitis, measles, mumps and rubella in university students

A serological study of 433 university students in various health care professions revealed levels of susceptibility of 2-7% for measles, 0-4% for mumps, 6-17% for poliomyelitis and a particularly disquieting 13-23% for rubella. Representing a developed population with a supposedly high level of immunisation cover these levels of susceptibility indicate students' vulnerability to outbreaks caused by viruses coming from reservoirs in under-immunised developing populations in the country. Nevertheless, no evidence of occupational exposure between the first- and final-year students was revealed. Immunisation efforts thus need to be urgently targeted not only to developing but also to developed populations in South Africa.     

Colorectal cancer in young blacks. An epidemic in Gazankulu?

Eight cases of colorectal cancer at Elim and Malamulele Hospitals, Gazankulu, occurring in a 7-month period in young black people, are presented. Epidemiological and aetiological considerations are discussed.     

Global health strategies versus local primary health care priorities--a case study of national immunisation days in Southern Africa.

Building on the successful eradication of smallpox, the World Health Organisation, together with other agencies, is now moving quickly to the eradication of poliomyelitis, originally aimed for the year 2000. Plans for the subsequent global eradication of measles are in an advanced stage. Eradication of both polio and measles incorporate as a fundamental strategy high routine coverage, surveillance and special national immunisation days (NIDs), which are supplementary to routine vaccination services. There has been a lively debate on whether poor countries, with many health problems that could be controlled, should divert their limited resources for a global goal of eradication that may have low priority for their children. From a cost-effectiveness perspective, NIDs are fully justifiable. However, field observations in sub-saharan Africa show that NIDs divert resources and, to a certain extent, attention from the development of comprehensive primary health care (PHC). The routine immunisation coverage rates dropped on average since the introduction of NIDs in 1996, which is contrary to what was observed in the western Pacific and other regions. The additional investment to be made when moving from disease control to eradication may exceed the financial capacity of an individual country. Since the industrialised countries benefit most from eradication, they should take responsibility for covering the needs of those countries that cannot afford the investment. The WHO's frequent argument that NIDs are promotive to PHC is not confirmed in the southern African region. The authors think that the WHO should, therefore, focus its attention on diminishing the negative side-effects of NIDs and on getting the positive side-effects incorporated in the integrated health services in a sustainable way.     

Immunisation coverage and reasons associated with non-immunisation in Alexandra township, September 1988

Regular annual measles outbreaks in Alexandra prompted a revision of immunisation strategies at the Alexandra Health Centre and University Clinic (AHC) and an immunisation coverage survey in September 1988. Forty-five clusters of 7 children aged 12-23 months were studied. Eighty-two per cent of mothers were in possession of a 'Road to Health' card, 12% said they had the card elsewhere, 3% reported it lost and 3% had never had a card. Thirty-three per cent of the children completed the immunisation schedule on time, 50% by 1 year of age and 61% by the time of the interview. The influence of sociodemographic, immunisation knowledge, and health service access variables on immunisation rates were analysed. Those children with a non-AHC 'Road to Health' card (P less than 0.01), the squatters (P less than 0.05), and those living farthest away from the clinic (P less than 0.05) were the only groups with a statistically significant lower on-time immunisation rate. Those children with a non-AHC 'Road to Health' card (P less than 0.01) and those whose caregivers could not or had difficulty reading a simple message in English (P less than 0.01 and P less than 0.05, respectively) had a significantly lower immunisation rate by 1 year of age and by interview. A child health outreach programme, started immediately after the survey, has begun to address some of the determinants of immunisation uptake described in this survey.     

BCG vaccination and the EPI

BCG vaccination for newborns has been compulsory by law in the RSA since 1973. From limited published information, it appears that coverage has now reached more than 80%. However, the effectiveness of the vaccinations in terms of disease prevention in the young is unknown. Small studies indicate protection of approximately 60% against all forms of tuberculosis in infants, but this figure is not generalisable. It is pointed out that the contribution of BCG vaccination to an overall decline of tuberculosis rates is minimal and should not be considered as a measurement of success of the EPI. The prevalence and risk of infection in southern African children is such that a policy of reduction or withdrawal of BCG vaccination from some sections of the community is not feasible. The current strategy of compulsory BCG vaccination at birth, followed by repeat vaccination 3 months later in children without evidence of reactivity at the vaccination site, as well as revaccination at school entry and school leaving, is both adequate and necessary. A standardised immunisation data recording format and full exchange of information at all decision-making levels between the EPI and the tuberculosis control programme is called for.     

Strategies for predicting and treating access induced ischemic steal syndrome.

Access induced ischemia is an uncommon but devastating complication for patients maintained on hemodialysis. A number of clinical risk factors have been identified to select patients at risk. Intraoperative measurement of the digital-brachial index may further distinguish at-risk patients when the DBI is <0.45. Once clinically significant steal has developed, surgical strategies to treat this problem should ideally reverse the ischemia while maintaining uninterrupted access for hemodialysis. To date, the distal revascularization-interval ligation or DRIL procedure has been the most consistently successful tactic in achieving these dual objectives. A number of alternative strategies have recently been proposed and will be discussed.     

Vaccination status of under-5s in northern Gazankulu, 1985

An assessment of the immunisation status of children under the age of 5 years in the Elim health ward was undertaken in September 1985. A modified EPI technique for random cluster sampling was used. The advantages of this modification are discussed. In total, 480 children were selected. Of these, 83.5% possessed a 'Road to Health' card, 93.5% had had 3 or 4 doses of DPT vaccine, 92.1% had had 3 or 4 doses of polio vaccine, and 84.3% had had 1 dose of measles vaccine. The percentage of children of 18 months and older who received a fourth dose of either DPT or polio vaccine was 65.9% and 68.5% respectively. The vaccination status of younger children is better than that of older children and this is probably due to recent improvements in the vaccination services. It is recommended that the proportion of children who receive a fourth dose of DPT and polio vaccine should be increased and that completed vaccination is made an entrance requirement for primary schools.     

Support systems, facilities and staffing of clinics in Mhala, Gazankulu--are they adequate?

A study comprising in-depth interviews of sisters in all 15 rural clinics in the Mhala district of Gazankulu showed them to experience major problems with support systems: radiophone communication was unreliable (and even absent in 3 clinics); transport was inadequate; the cold chain was not well maintained and essential drugs and equipment were absent (only 1 clinic had all the equipment to manage a neonatal resuscitation adequately). There were also serious deficiencies in facilities, lack of running water and electricity posing the most serious problems (resulting in deliveries and suturing of episiotomies by candlelight). Other pressing problems include inadequate waiting space and patient privacy. Staffing at the clinics fell well below what is required, yet the commitment of staff was often inspiring. The state of the clinics must be seen within the constraints of 'homeland' policy and the unequal distribution of the country's health care resources. Despite these limitations the clinic service can be improved. Recommendations are made for this, concentrating on improving support structures rather than on the more costly improvement of facilities.     

Iron and folate status of pregnant black women in Gazankulu

A limited nutritional survey was carried out in 229 first attenders at an antenatal clinic in Gazankulu during the winter of 1984. Haemoglobin concentrations equal to or less than 11 g/dl were found in 33% of these women, the prime reason being folate deficiency. Serum folate concentrations were less than a 3.5 ng/ml in 60% of subjects and less than 3.0 ng/ml in 48%. A mean corpuscular volume of 100 fl or more, which reflects a defect in red cell DNA synthesis, was present in 35%. Iron related measurements indicated that only 17% were also iron deficient but the figure is certainly an underestimate, since the presence of folate deficiency tends to mask concomitant iron deficiency. The findings underline the need for folate and iron supplementation in pregnancy; the very high prevalence of significant folate deficiency also indicates that serious consideration should be given to the fortification of maize meal with folic acid.     

Analysis of an immunisation programme in a rural area

An immunisation programme in a rural area of southern Africa is analysed. The combination of fixed and mobile immunisation points is discussed with reference to staffing levels, patient convenience, vaccine handling, costs and efficiency. A system of community involvement in the programme is assessed. Mobile immunisation teams to complement fixed clinic services, and active community involvement are suggested for immunisation programmes in rural areas.     

Vaccination status and seroprevalence of measles and polio antibodies in 1-6-year-old children in the Elim health ward of Gazankulu

Seroprevalence was used to evaluate the vaccination programme in the Elim health ward of Gazankulu. Antibodies to measles and polio were measured in 1-6-year-old children together with vaccination status. In 224 children studied using a cluster sampling technique, vaccine coverage was found to be 86% for measles and over 90% for polio and diphtheria, pertussis and tetanus. It was difficult to determine vaccine failure rates accurately; 21% of children were seronegative after having received measles vaccine, 32% who had apparently not been vaccinated had antibodies, while a total of 27% had no measles antibodies. Thirty-nine per cent of children failed to demonstrate antibodies to all 3 types of poliovirus after having received 3 doses of oral polio vaccine, 94% had immunity against type 2, and 76% and 74% were immune to types 1 and 3, respectively. Reasons for diminished effectiveness of vaccination programmes are cited; in this study it was probably due to decreased vaccine efficacy related to inadequacies in the cold-chain. Recommendations are that seroprevalence studies are useful, but only after vaccine coverage and the cold-chain have been optimised.     

Missed opportunities for measles immunisation in selected western Cape hospitals

Measles is still a major cause of childhood mortality and morbidity in South Africa. The World Health Organisation (WHO) has recently recommended that greater attention be paid to opportunities for immunisation in the curative sector. This study quantified the extent of missed opportunities for measles immunisation in children attending primary, secondary and tertiary level curative hospitals in the western Cape. Exit interviews of 1,068 carers of children aged between 6 and 59 months inclusive showed that 2.4-40.7% of carers had been requested to produce a Road-to-Health card, and that 4.8-43.1% of carers had a card available. The proportion of children with documented evidence of measles immunisation available ranged from 4.8% to 40.0% between facilities. The study demonstrated that a considerable number of potential opportunities to immunise children against measles are currently being missed in children attending hospitals and day hospitals in the western Cape. The study documents the effect of a fragmented approach to health care, and indicates a need for rapid integration of preventive and curative components of health care into a metropolitan-based primary health care service.     

Solving multi‐objective dynamic optimization problems with fuzzy satisfying method

This article proposes a novel algorithm integrating iterative dynamic programming and fuzzy aggregation to solve multi‐objective optimal control problems. First, the optimal control policies involving these objectives are sequentially determined. A payoff table is then established by applying each optimal policy in series to evaluate these multiple objectives. Considering the imprecise nature of decision‐maker's judgment, these multiple objectives are viewed as fuzzy variables. Simple monotonic increasing or decreasing membership functions are then defined for degrees of satisfaction for these linguistic objective functions. The optimal control policy is finally searched by maximizing the aggregated fuzzy decision values. The proposed method is rather easy to implement. Two chemical processes, Nylon 6 batch polymerization and Penicillin G fed‐batch fermentation, are used to demonstrate that the method has a significant potential to solve real industrial problems. Copyright © 2003 John Wiley & Sons, Ltd.     

Needlestick injuries in anaesthetists

A survey of needlestick injuries among 42 anaesthetists at this university hospital was carried out over a 3-month period to ascertain the rate of occurrence and the extent to which a revised protocol for the management of such injuries was followed. There were nine reported incidents, of which six were with contaminated needles. Three were reported. Eight anaesthetists had not taken up immunisation against hepatitis B. The rationale behind the revised protocol, and possible reasons for poor compliance are discussed.