Andrea S. Vicari

Immunization And The Millennium Development Goals: Progress And Challenges In Latin America And The Caribbean

The child mortality rate has been greatly reduced in Latin America and the Caribbean (LAC). More than half of the gains in reducing child mortality are attributable to immunization. The Revolving Fund of the Pan American Health Organization contributed to this achievement by catalyzing policy innovations that sustained national immunization programs, such as vaccine legislation and budgetary decrees to ensure delivery of services. In addition to measuring the impact of immunization on the child mortality reduction target of the Millennium Development Goals in the LAC region, this paper provides a policy framework to ensure that the rest of the target is reached.

The global inter-relatedness of disease control

The Lancet Infectious Diseases has highlighted the crucial need to stress the global inter-relatedness of control of infectious diseases. Control of vaccine-preventable diseases across borders is a key function of the regional immunisation programme of the Pan American Health Organization (PAHO). PAHO’s regional programme is grounded in the following core values: inter-country co operation; capacity to identify problems and design appropriate solutions; capacity to sustain interventions; strong political commitment; sound programme management; national plans of action; well-functioning technical oversight and partner coordination; enhanced tech nical cooperation in high priority countries; cross-border cooperation; and the ability to respond to exceptional circumstances. The outbreak that occurred in Venezuela between September, 2001, and November, 2002, was the last instance of widespread measles virus circulation in the western hemisphere. However, sporadic cases and outbreaks associated with importations continue to occur after the disease has been eliminated (panel). These measles outbreaks associated with import ations draw attention to the tremendous challenge that PAHO and member countries have to protect and sustain the progress achieved in measles elimination in the Americas. In the post-elimination phase of measles control in the Americas, all these import-related outbreaks require an extraordinary amount of time and resources (both human and fi nancial). Re-establishment of endemic measles virus circulation in the Americas upon importation remains a distinct possibility and would undo substantial progress in reducing child mortality, one of the eight UN Millennium Development Goals. In September, 2003, the Directing Council of the PAHO adopted the resolution to eliminate rubella and congenital rubella syndrome in the Americas by the year 2010. This initiative was largely launched on the heels of the success of measles elimination. Keeping the region free of both measles and rubella will require continued actions to strengthen global cooperation of measles and rubella control, and will hopefully provide more lessons learned for an eff ective response to any pending global pandemic of infl uenza.

Outbreak of rotavirus gastroenteritis with high mortality, Nicaragua, 2005

OBJECTIVES We investigated a nationwide outbreak of severe rotavirus gastroenteritis in Nicaragua in children under 5 years old, leading to many consultations, hospitalizations, and deaths. We questioned whether a vaccine might have prevented these illnesses and deaths, sought to identify risk factors for death, and developed a clinical profile of children hospitalized with diarrhea. METHODS We conducted a case-control study to determine whether children who died had access to routine immunizations, a proxy predicting access to a rotavirus vaccine. We identified risk factors for death among children who died in the outbreak compared with surviving age-matched controls with diarrhea. We collected stools, clinical data, and immunization data on children hospitalized for diarrhea to test for rotavirus, develop the profile, and forecast future access to a rotavirus vaccine. RESULTS The outbreak from February to April 2005 caused 47 470 consultations and 52 deaths. Approximately 80% of cases and controls and 60% of children hospitalized with diarrhea had access to routine immunizations and would likely have had access to a rotavirus vaccine. With a vaccine efficacy of 85%, up to 51% of severe rotavirus cases and up to 68% of deaths could have been prevented if a rotavirus vaccine were available as part of routine childhood immunizations. Study of 35 case-control pairs indicated that severe illnesses, malnutrition, and care by traditional healers were risk factors for death. Rotavirus was found in 42% of samples from hospitalized children and was associated with severe disease and dehydration. CONCLUSIONS The impact of the seasonal outbreaks of rotavirus disease could be diminished with a rotavirus vaccine, improvements in oral rehydration programs, and training of traditional healers in the proper management of children with acute diarrhea.

Genital human papillomaviruses among women of reproductive age in Jamaica

OBJECTIVE To characterize the prevalence and distribution of genital human papillomavirus (HPV) types among women in Jamaica, and to explore risk factors associated with HPV infection. METHODS This was a cross-sectional study that took place in April-July 2010 with 852 sexually-active women, 16-49 years of age, who had attended a selected public or private primary health clinic in one of Jamaicas four health authority regions. Sociodemographic data was collected from each participant by trained study staff. Each participant had a gynecological examination that included a clinical Pap test and a cervical sample for HPV detection and typing-performed using the Research Use Only Linear Array (LA) genotyping assay (Roche Diagnostics Corp., Indianapolis, Indiana, United States). Overall and type-specific prevalence of HPV infection was calculated for 37 HPV types included in the LA genotyping assay. RESULTS HPV DNA was detected in 460 of the 852 women (54.0%). Oncogenic HPV was detected in 297 women (34.9%) and HPV types 16/18 were found in 86 women (10.1%). The most frequently occurring HPV types were: 16 (6.2%); 35 (6.0%); 62 and 83 (5.5%); 61 and 58 (5.4%); 84 (4.7%); 18 (4.3%); and, 66 and 81 (4.2%). HPV prevalence was highest among women who were single, young (16-19 years), and had had more than three sexual partners in their lifetime. CONCLUSIONS These results, coupled with high rates of cervical cancer, support introducing HPV vaccines while maintaining and strengthening cervical cancer screening services. Policy decision-making that reflects these results is instrumental to establishing a comprehensive cervical cancer program in Jamaica.

Providing Vaccines Against Human Papillomavirus To Adolescent Girls In The Americas: Battling Cervical Cancer, Improving Overall Health

Vaccines against the human papillomavirus (HPV)--the primary cause of cervical cancer--target adolescent girls, many of whom have limited contact with health services. Countries in the Americas are beginning to use HPV vaccines to increase the impact of cervical cancer programs and as an entry point to broader health services for girls. This strategy opens new opportunities to improve lifelong health habits; encourage regular cervical cancer screening and treatment, when necessary; and offer associated services such as reproductive health and nutrition guidance. Some of the early experiences with this strategy illustrate challenges and opportunities that may arise with other new vaccines.

Development of a Cholera Vaccination Policy on the Island of Hispaniola, 2010–2013

Deployment of oral cholera vaccine (OCV) on the Island of Hispaniola has been considered since the emergence of the disease in October of 2010. At that time, emergency response focused on the time-tested measures of treatment to prevent deaths and sanitation to diminish transmission. Use of the limited amount of vaccine available in the global market was recommended for demonstration activities, which were carried out in 2012. As transmission continues, vaccination was recommended in Haiti as one component of a comprehensive initiative supported by an international coalition to eliminate cholera on the Island of Hispaniola. Leveraging its delivery to strengthen other cholera prevention measures and immunization services, a phased OCV introduction is pursued in accordance with global vaccine supply. Not mutually exclusive or sequential deployment options include routine immunization for children over the age of 1 year and campaigns in vulnerable metropolitan areas or rural areas with limited access to health services.

Rubella and Congenital Rubella Syndrome Elimination Activities: Colombia, 2005–2006

As part of regional commitments in the Americas aimed at elimination of rubella and congenital rubella syndrome, and consolidation of measles elimination, Colombia conducted mass vaccination of males and females aged 14-39 years in 2005-2006. The target population included 18,238< 443 persons (44% of the entire population). Vaccination activities were extended because of limited participation and public concerns about vaccine safety. Over a 10-month peroid, 17,697,717 doses of measles-rubella vaccine were administered, reaching 97% of the target population, including 96.4% of females and 97.6% of males. Estimated coverage exceeded 95% in 33 of 36 departments and districts, and in 3 others, it ranged from 92% to 95%. In rapid monitoring conducted in 504 (45%) of 1119 municipalities, 95% of persons in the target population were vaccinated. The Colombian experience underscores the importance of social mobilization at the local level, political commitment, and microplanning and offers lessons for future mass vaccination campaigns.