Sudanese Journal of Paediatrics 1984; 3: 71.- 83

CURRENT ISSUES

The Sudan Association of PaediatriciansThe Sixth Conference of the Sudan Association of

Paediatricians (SAP) was held in EI Fao in December 1982.This small town - being a budding settlement area in alarge newly-born agricultural project - was chosen tosymbolize the theme of the conference i.e. priorities inprimary health care. The conference has been designed bythe organising committee in the form of a workshop todiscuss and formulate specific recommendations to helpshaping a national plan regarding the pressing issues ofchild health in the Sudan. During the three days of theworkshop, participants - including most of SAP membersand representatives of distinguished local and interna-tional bodies dealing with child health - took activepart in the three committees to which the workshop hasbeen divided. These dealt with diarrhoeal diseases,malnutrition and immunization.

In this issue we included the recommendations of theCommittee on Immunization and also cited the conclusionsof the WHO/IPA Workshop on Immunization that preceded the .XVII International Congress of ~aediatrics. It is hopedthat this will intensify the increasing awareness amongstSAP members of the activities of the Expanded Programmeon Immunization Project which is currently undertaken inthe Sudan.

WORKSHOP ON PRIORITIES IN PRIMARY HEALTH(FAO DECEMBER, 1982)

RECOMMENDATION OF THE COMMITTEE ON IMMUNIZATIONA major area of concern in improving health care

delivery in any developing country is the operation of aneffective immunization programme. The World Health Orga-nization (WHO) has made a goal in that direction in itsResolution 27/57. This aims to reduce morbidity andmortality from diphtheria, partusses, tetanus, measles,poliomyelitis and tuberculosis by providing immunizationagainst these diseases for every child in the world bythe year 1990. These childhood diseases were found in arecent survey conducted in the year 1979 to account for32% of all deaths in eleven major cities in Sudan amongstpre-school children, let alone the less-privileged areas.

I

72 Recommendation of the Committee onIm m unization

The country is .therefore committed to an expanded immu-nization programme to reduce the magnitude of thisproblem and meet at the end the targets stated in the WHOresolution 27/57.1. The immunization pannel - after thorough dis-cussion - approved of and adopted the goals stated in thepaper presented by the Central Office of the ExpandedProgramme on Immunization (EPI) Project. This aims incollaboration with other health services and non-govern-mental organizations at:

(a) Short term policy: 80% coverage of eligiblechildren in 45 centres (towns) and surrounding areas of 2to 4 hours drive radius and 75% of Gezira province.

(b) Long term policy: to cover 80% of the eligiblechildren in each accessible primary health care (PRC)population and functioning PRC units, with the aim ofmeeting the targets stated in the WHO resolution 27/57.2. The pannel is aware of the vital importance ofthe notification of the above-mentioned childhood dis-eases in all hospitals both inpatients and outpatients.In the way of improving that the pannel strongly recom-mended:

(a) Providing adequate clerical facilities fornotification and keeping a record system in the variouspaediatric units throughout the country being supervisedby the paediatricians concerned.

(b) Improving the existing infection disease units(the so-called quarantines) to provide a better recordand better patients' care.

(c) Encouraging the implementation of diseasesurveys when necessary. This will work as a feedback forthe immunization programme and encourage those who areinvolved e.g. paediatricians to conduct researches inthat respect.3. (a) The pannel adopted the immunization schedulefollowed by the EPI which consists of:o BCG at birth or first contact with the babyo First dose of oral polio vaccine (OPV) and triple

vaccine (DPT) at 3 monthso Second dose of OPV and DPT at 4 monthso Third dose of OPV and DPT at 5 monthso Measles vaccine at 9 monthso School entry: Diphtheria/tetanus, OPV and BCG

Recommendation of the Committee on 73Im munization

This schedule is ment to be flexible and no maximalintervals need to be drawn bet~een the first, second andthird doses. Moreover, the child can have OPV, DPT andmeasles vaccine at the same time if the parents deferredthe third contact to the 9th month.

(b) In 2-3 years time this schedule can be coupledwith another campaign style schedule which needs only twocontacts with the child of 6 months intervall to allowfor effective coverage of rural areas with no existinghealth services. The PHC units will then act as focalpoints for conducting these campaigns. However, furtherresearch is recommended to be done in this respect toevaluate the efficiency of such programmes.

(c) The pannel approved of unifying the site ofinjecting the DPT vaccine i.e. the lateral side of thethigh to limit the chance and extent of provocationparalysis. Site of BCG should be the upper lateral aspectof left forearm.4. (a) The pannel was informed by the EPI directorabout the cost of the programme and was assured that thecost would not be prohibitive for at least the comming 5years.

(b) It also admired the efficacy and practica-bility of the "cold chain" system and vaccine monitoringdevices followed by the EPI Central Office in Khartoum.

(c) Weak links in the "cold chain" could be moni-tored by recording the temperature exposure hitory ofvaccines as they pass through the different points in thE'disbribution system. However, more help is needed fromthe Regional Governments to assure continued supply offuel and maintenance parts for the various items of the"cold chain" e.g. generators, cars, refrigerators. Thepannel suggests that the Regional Governments should makea separate item within. the health service budget for EPIactivities in each region to cover these minor expenses.5. The pannel has approved of the delivery ofchildhood immunization in Sudan within the context of thePrimary Health Care Programme (PHCP). The role of eachpartner was discussed thoroughly and table was compiledto delineate the duties of manpower at the various levels(Table I).

Table IRoles and duties of manpower in the implementation of suggested immunization programme

Manpower

1. Village midwife2. Primary health care worker (PHCW)/

nurse/vaccinator3. Assistant sanitary overseer4. Medical assistant/health visitor5. PHCW tutor6. Health education officer7. Nutrition officer8. EPI operation officer9. Midwife inspector10. Council medical assistant11. Public health officer12. Medical officer13. Me~i~al inspector14. Paediatrician and obstetrician15. Community physicians (at all levels)16. National director of EPI

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Recommendation of the Committee on 75Im m unization

The EPI Central Office in Khartoum is only res-ponsible for technical supervision, guidance, evaluationand supplies of the necessary logistics. In each provincea steering committee with the paediatrician playing amajor role and including an EPI operation officer asconvenor, community physician, obstetrician, peoplesorganization representatives, will be in charge of localplanning implementation and supervision of the programmewithin the context of the regional health authority. Thesteering committee will act as the top of a pyramid, thebase of which consists of the village midwife and theprimary health care worker (being a nurse or vaccinator).6. Health education. The pannel was quite aware ofthe vital role of health education in supporting theprogramme which can be effectively executed through:

(a) Mass media:o Television: short films and slideso Radio: public announcements, short songs etco Posters: the help of the Graphic Department of theFaculty of Fine Arts would be appropriate in this respect.

(b) Curricula: should be given priority in:o Medical schools: where sound knowledge of the theo-retical background and technique of immunization and themaintenance of the "cold chain", is needed both by themedical students and the postgraduate doctors. Curriculaof medical assistant, nurses, midwives and communityhealth workers should also be strengthened in this aspect.o Primary, intermediate and secondary schools curri-cula should be improved to ensure effective child, child-to-child, child-to-parents and future parents' educationabout the importance of vaccination. Ideas in this lineare providing schools with booklets published by EPICentral Office and exercise books with back-coversillustrating the immunization schedule and instructionsabout it.

(c) Influencing decision makers by involving themdirectly or indirectly in the steering committee of thedifferent provinces and by personal communication throughthose who hold key health positions in the provinces:e.g. paediatricians, obstetricians and communityphysicians.

(d) Influencing pressure groups through speciallydesigned talks and short seminars.

76 Recom mendation of the Committee onIm m unization

7. The pannel discussed the importance of en-dorsing laws and legislations by the various healthauthorities to back the immunization programme e.g.penalizing defaulting parents. It was agreed upon thatsuch measures should not be taken without assuring ade-quate and convenient immunization services in thisdistrict. However, whenever there is any vaccinationactivity in the villages legislations to discouragedefaulters should be implemented being supported byhealth education.8. Evaluation. The group agreed upon the vitalimportance of evaluating the efficacy of the programme.This includes:

(a) Coverage evaluation: carried out periodicallyto ensure adequate immunization coverage in the variousdistricts.

(b) Measuring antibody levels in children for thediseases included in the immunization programme. -

(c) Survey and studies of immunizable diseases: tosee whether reduction of incidence is achieved in 5-7years time.

(d) Evaluation of the "cold chain".'(e) Auditing of the programme periodically.

9. Certain problems directly related to immuni-.zation were discussed and decisions were made about them.These included:

(a) Whooping cough encephalopathy: The pannel wasaware of the fact that the advantages in term of pro-tection for children of Sudan outweighs the risks of theadverse reactions of the vaccine.

(b) Tetanus antiserum (ATS): Its wide use in theSudan (due to its low cost) for all types of wounds isquite hazardous (anaphylaxis etc). Two doses of thetoxoid should replace ATS whenever possible.

(c) Rabies vaccine: Research and measures to enhancethe elimination of the vaccine used now are stronglyrecommended and the human antirabies vaccine - though itscost is prohibitive - should be available for at leastthe health personnel who are at risk of managing cases ofrabies in the various districts etc.

(d) Meningitis and typhoid: Those diseases need notbe included in a national immunization programme sincethey can be dealt with by other measures. Moreover the

77 WHO/IPA workshop on Immunisation

cost/efficacy of either of them does not justify theirroutine use.

Contents of such diseases should be within theresponsibilities of the Epidemiology Department.

XVII INTERNATIONAL CONGRESS OF PAEDIATRICSWHOjIPA PRE-CONGRESS WORKSHOP ON IMMUNIZATION

CONCLUSIONS AND RECOMMENDATIONS7 November 1983

1. IntroductionPaediatricians have long taken a leading role in the

delivery of immunizations and their influence oftenextends beyond the families under their care. Their rolein preventing disease could be further extended if theNational and International Associations become involvedwith and support the World Health Organization ExpandedProgramme on Immunization (EPI)i.

A Pre-Congress Workshop on Immunization for the XVIIInternational Congress of Paediatrics was held at theWorld Health Organization Regional Office for the WesternPacific, 6-7 November 1983. During the workshop, technicalpapers were presented dealing with new vaccine developmentand conclusions and recommendations to promote the appli-cation of immunization services. Specific recommendationsfollow:2. Support for the expanded programme on immunization

Despite being one of the most powerful and costeffective weapons of modern medicine, immunization remainstragically unavailable or under-utilized, particularly inthe developing world. As a consequence some five millionchildren die from vaccine preventable diseases each year:ten children with each passing minute. An equal numberare blinded, crippled or left with mental retardation.

iEstablished by the World Health Assembly in 1974, theEPI seeks to expand the geographic coverage of existingimmunization services and to expand the number of vac-cines of public health importance included within nationalimmunization programmes.