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more cases in males which agrees with other reports from Ethiopia.5 – 7,10 Although there might be predisposing factors that we do not know about, it could also just be because some families are more likely to take males to hospital. The mean duration of the illness was shorter in most of the reported series in adults and in children.1,5,6 In contrast to previous studies,5 we have not found a shorter duration of symptoms before admission to hospital in children than in adults. The clinical features of LBRF in childhood are similar to those in adults.6 – 8 However, we find clinical differences between paediatric and adult patients with less common symptoms like headache, dizziness or other pains, which could be attributed to the fact that children are less capable of communicating their problems.6 But there were also significant differences in objective features such as bleeding, which was less frequent in children and which suggests that there really are important clinical differences in the presentation of the disease among these two age groups. The treatment was also different for children and adults; tetracycline being used more frequently for adults and penicillin or erythromycin for children which agrees with previous reports.4 The overall case fatality in our series was low, as in previous reports (,3%).6 – 8 When we compared the fatality rates among children and adults, like other authors, we had fewer mortalities among children.1 – 5 The hospitalization was shorter for children (average 3.7 days) which is a similar result reported in other studies.5 – 6 In conclusion, many symptoms of LBRF occur less frequently in children than in adults and the prognosis is better in most of the reports from Ethiopia.
9 Ramos JM, Malmierca E, Reyes F, et al. Characteristics of louse-borne relapsing fever in Ethiopian children and adults. Ann Trop Med Parasitol 2004;98:191– 6 10 Mekasha A, Meharie S. Outbreak of louse-borne relapsing fever in Jimma, south western Ethiopia. East Afr Med J 1996;73:54–8
Acknowledgements
TROPICAL DOCTOR 2009; 39: 36– 38 DOI: 10.1258/td.2008.070444
We thank the nursing and laboratory staff at the Gambo Rural General Hospital for their help in this study.
References 1 Borgnolo G, Haiku B, Ciancarelli A, Almaviva M, Woldemariam T. Louse-borne relapsing fever. A clinical and an epidemiological study of 389 patients in Asella Hospital, Ethiopia. Trop Geogr Med 1993;45:66 –9 2 Brown V, Larouze B, Desve G, et al. Clinical presentation of louse-borne relapsing fever among Ethiopian refugees in northern Somalia. Ann Trop Med Parasitol 1988;82:499–502 3 Sundnes KO, Haimanot AT. Epidemic of louse-borne relapsing fever in Ethiopia. Lancet 1993;342:1213– 15 4 Seboxa T, Rahlenbeck SI. Treatment of louse-borne relapsing fever with low dose penicillin or tetracycline: a clinical trial. Scand J Infect Dis 1995;27:29 –31 5 Mitiku K, Mengistu G. Relapsing fever in Gondar, Ethiopia. East Afr Med J 2002;79:85– 7 6 Mekasha A. Louse-borne relapsing fever in children. J Trop Med Hyg 1992;95:206–9 7 Daniel E, Beyene H, Tessema T. Relapsing fever in children – demographic, social and clinical features. Ethiop Med J 1992;30: 207– 14 8 Borgnolo G, Denku B, Chiabrera F, Hailu B. Louse-borne relapsing fever in Ethiopian children: a clinical study. Ann Trop Paediatr 1993;13:165–71
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The Philippines 2004 measles campaign: a success story towards elimination Howard Sobel MD MPH* Joyce Ducusin MD MPH† Maricel De Quiroz RN† Myrna Cabotaje MD MPH† Jean-Marc Olive´ MD MPH* *World Health Organization, Office of the Representative, 2/F, Bldg 9, DOH, San Lazaro Hospital, Sta Cruz, Manila; † Department of Health, San Lazaro Hospital, Sta Cruz, Manila, Philippines Correspondence to: Dr Howard Sobel, World Health Organisation, Office of the Representative, 2/F, Bldg 9, DOH, San Lazaro Hospital, Sta Cruz, Manila, Phillippines Email:
[email protected]
SUMMARY Prior to the 2004 Philippines Measles Follow up Elimination Campaign, measles caused an estimated 6000 deaths among Filipino children. After the campaign, cases and deaths decreased by 96.4% and 99.2%, respectively.The Nationwide Rapid Coverage Assessments, with an extensive system of feedback, was the prime factor in reaching the under-immunized areas.
Introduction In 2003 an estimated 6000 Filipino children died from measles.1 Poor children are at the highest risk and have the least access to basic public health services.2 Fourteen million Filipinos live on less than USD1 per day.3 The Philippines is one of the 42 countries that account for 90% of global deaths in under 5 year old children.4 Reaching under-immunized populations requires focused efforts: 96% of children aged 9 months – 15 years were reportedly vaccinated during a 1998 nationwide measles campaign. Measles cases only marginally decreased which suggests that pockets of unimmunized children remained.5 Other countries have had similar experiences.6 Countries in the Americas use Rapid Coverage Assessments (RCA) where supervisors review the immunization status of 20 children in each community. When two or more unimmunized
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children were found, supervisors re-initiated vaccination activities.7 The 2004 Philippines Follow up Measles Elimination Campaign (PFMEC) aimed to vaccinate 18 million children aged 9 months to 8 years against measles. Pre-campaign key informant interviews, data analysis and planning workshops revealed that: 50% (9860) more vaccinators were needed than were available at the time; the door-to-door strategy would not be widely used; the population estimate was unreliable; and local health workers felt that as they had undertaken similar activities before they did not need extra training. The Philippines instituted RCA, along with an extensive feedback system, during the 2004 PFMEC to focus attention on reaching the under-immunized population.
Methods The campaign outcome was assessed by measuring the number of measles cases and deaths identified in the National Epidemic Sentinel Surveillance System (NESSS) during the five years before and two years after the campaign. A suspect measles case is defined as an illness with three days of fever, maculo-papular rash, accompanied by cough, coryza or conjunctivitis. Initiated in 1993, NESSS is an active surveillance system for 14 notifiable diseases, including measles, from 228 hospitals covering all 17 regions. Attending staff and hospital infection control teams investigate all suspect cases, including specimen collections. They submit investigation forms to the Regional Epidemic Surveillance Unit who report to the National Epidemic Center monthly. Data is entered into the NESSS database. Twenty-eight hospitals in 14 regions had at least a 100-bed capacity, weekly active measles surveillance and reported cases every year between 2003 and 2005 (referred hereafter
as High-Performing Sentinel Sites [HPSS]). Six of these have more than 50% of their clientele residing in rural areas. Measles serology testing began in 1999. Blood specimens were sent to the Research Institute of Tropical Medicine (RITM) in Manila for IgM testing by ELISA. They are part of the World Health Organization (WHO) Western Pacific Regional laboratory network and have consistently passed WHO proficiency testing. We compared the average number of reported measles cases, deaths, the proportion of specimens positive for IgM serology and the proportion of suspect measles cases that had received measles vaccination for the five years before the start of the campaign (January 1999-December 2003) with those two years after the campaign (April 2004-March 2006). We also used the same analysis for the 28 HPSS and the six rural HPSS, comparing the same periods. Percentage decrease is defined as: 5-year average annual cases pre-campaign 1–2-year average cases post-campaign 100% 5-year average annual cases pre-campaign
Results Measles cases reported to the NESSS during 1995– 2003 ranged from 100 to 1000 per month (Figure 1). Reported cases and deaths decreased by 96.4% and 99.2%, respectively, after the campaign compared to the five years prior to the campaign (Table 1). These results are consistent whether comparing all NESSS cases or those from any or just rural HPSS. Between 1995 and 2003, 19.3% of suspect measles cases reported to NESSS were vaccinated. This increased to 44%
Figure 1 The 10-year trends of monthly hospitalized measles cases for the Philippines and in high-performing sentinel sites
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Table 1 Comparison of measles surveillance parameters two years after and five years before the campaign
Surveillance parameter Measles cases in 228 sentinel hospitals Measles deaths in 228 sentinel hospitals Measles cases in 28 HPSH Measles cases in six HPRH
Average annual cases (January 1999-December 2003
Average annual cases (April 2004-March 2006)
Decrease (%)
7608.2
277.5
96.4
269.4
2
99.2
4720.2
124.5
97.4
9.5
93.7
150
HPSH, high-performing sentinel hospitals; HPRH, high-performing rural hospitals
during the two years following the campaign, peaking at 60% in 2005. Between 1999 and 2003, 83.9% (8299/9887) of specimens tested for IgM serology were confirmed as measles. This decreased to 14.9% (26/174) during the two years following the campaign and none occurred after June 2004.
Discussion After 10 years of reported measles cases, deaths, vaccination status of cases and five years of IgM positive serology the situation was stabilized and dramatically improved after the campaign. HPSS followed this trend. Likewise, IgM positivity declined from above 80% to zero after June 2004. As none of these changed during previous campaigns, those campaigns probably did not penetrate the pockets of the under-immunized populations. We acknowledge that NESSS only detects hospitalized cases located in 228 of the 954 total hospitals (23.9%);8 and less than half of the suspect measles cases are serologically confirmed. However, the dramatically improved indicators found here, which cover all national regions, suggest the impact was strong. Effect of RCA In the Americas, RCA has proven to be an important adjunct to focusing campaigns on reaching at-risk populations.7 We found our repeated reports of low coverage alarmed politicians and health staff. Within three weeks, discussions about the RCA results caused five large regions and 13 cities to admit to falling short of their target. We then negotiated for an enforced door-to-door strategy and an area-wide validation. The Secretary of Health who validated the findings himself, issued a policy requiring nationwide validation and provided the support costs. Eventually, regional staff validated 17,333 districts and identified an estimated 26 times more with lower coverage than their international partners. The Secretary of Health, regional directors and health workers reported that validation exposed large unreached populations and prioritize them. RCA should be considered in any country where measles cases remain after a campaign has been conducted. It was
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particularly helpful in our set up where the authority to deliver health services is decentralized to local governments. National programmes cannot force local health teams to reach the unreached. 9 Rather, they must persuade and support regions, provinces, cities and municipalities to employ effective strategies. Extensive national pre-campaign advocacy and planning did not accomplish this. The nationally conducted validation of 41% districts identified that under-immunized populations existed. It made policymakers, politicians and health professionals aware that attaining international elimination targets and United Nations Millennium Development Goals meant that they had to reach those districts which had not been covered in previous surveys.10 References 1 Wolfson LJ, Strebel PM, Gacic-Dobo M, Hoekstra E, McFarland JW, Hersh BS. Has the 2005 measles mortality reduction goal been achieved? A natural history modeling study. Lancet 2007;369:191–200 2 Victora C, Wagstaff A, Armstrong-Schellenber J, Davidson G, Claeson M, Habicht J. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet 2003;362: 233– 41 3 International Monetary Fund. IMF Country Report No. 05/105. March 2005. Annex VII, page 64. Available at: http://www. imf.org/external/pubs/ft/scr/2005/cr05105.pdf 4 Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361:2226–34 5 McFarland J, Mansoor O, Yang B. Accelerated measles control in the Western Pacific Region. J Infect Dis 2003; 187:s246–s51 6 Cliff J, Simango A, Augusto O, Van der Paal L, Beillik R. Failure of targeted urban supplemental measles vaccination campaigns (1997– 1999) to prevent measles epidemics in Mozambique (1998–2001). J Infect Dis 2003;187(suppl 1): S51– 7 7 PAHO. Measles eradication: field guide. 2nd edn. Washington, D.C.: Pan American Health Orginization, 2005 8 Republic of the Philippines. Department of Health. Bureau of Health Facilities and Services. Licensed Government Hospitals and other Health Facilities. 2005. Available at: http:// www2.doh.gov.ph/bhfs/hosp/hosp05_gov.pdf 9 State of the World’s Vaccines and Immunization. Geneva, Switzerland: WHO, UNICEF and The World Bank, October 2002. Available at: www.who.int/vaccines-documents/ 10 United Nations General Assembly. A/Res/55/2: Agenda Item 60 (b). United Nations Millenium Declaration. 18 September 2000. Available at: http://www.un.org/millennium/declaration/ares552e.pdf
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