Expanded Program of Immunization - Somali Democratic Republic AID Assesibent July, 1979 Stanley 0. Foster and.Mike Marty. Center for DiseaseControl. Atlanta Ga. U.S.A. I Project Description II Scope of Work III Epidemiology,, IV Program Management *V Vaccines and Cold Chain VI; Mogadi hu.. VII, Middle Shabelli .VIII Lower Shabelli IX Conclusions X. Recomnnandati.ons Addenduhi-.'I '.'M'rgac:ishu Asessment Addendum, - ,II Jowhar Assessm6nt EXPANDED PROGAM OF IMMUNIZATION Project Description: Program of Immunization (EPI) is a long term.continuing The Expanded to individuals at risk to health activity to provide potent vaccines mortality. EPI is not a single vertical prevent morbidity and of Health but is a major initiative of the Somali Ministry program to provide a major to utilize all potential delivery systems preventive health service to the Somali people. be provided through three major program In Somalia EPI will Care M H Services, the proposed Primaiy Health initiatives: mobile teams. There Project (4 regions) and by regionally based centers in Somalia. Located in major urban. are currently 75 MCH source of current MCH centers serve as a potential centers, the 36.4% of the to an aggregate population of 1,035,000, service UNFPA to fund 55 MCH national total. The recent agreement with for 18 districts (Mogadishu, Korioley, assistants will provide urban and Wanle-WIein) one worker for each 1500 •Kurtunwaare, Balad, The proposed one.worke for.each 100.0 rural families. families.and basic component of : PHC-.pro'ect wil-l provide :i*mmunization as a " AID the above programs, Primary*Health Care..In areas not serviced by by regionally based mobile teams. immunizations.will be delivered 1978 with initiation of EPI in Somalia was launched in February in Mogadishu. The initial attach phase immunization activities was in December 1978 and maintenance vaccination was. completed 1979 regional to the 10 MCH centers. In February of assigned -.Middle Shabelli, Lower programs were initiated ii 4 regions; Shabelli, Toocler ,.and, Galbeed. .. II Team Scope of Vi'rk: " Initiative (Combating As part-of a major new AID African Health Diseases (CCCD)) Epidemiologists and Opera­ Childhood Communicable Center for being provided under a PASA with the tions Officers are EPI capability, Control "to assess the current country .Disease the country immunization collect data on the 6 EPI diseases, review recommendations for modifications, identify-training plan and make to AID Missions and and provide technical and logisticdata needs, the Development of AID-project host country Ministries of Health for Impact Program (AIP) criteria and papers using the Accelerated Somalia concurrence of the AID Mission and the foremat". With the Marty visited of Health Dr. Stanley Foster and Mr. Mike Ministry activities were reviewed Somalia from July 8-July 31, 1979. EPI Middle Shabelli, and Lower four levels Headquartes, Mogadishu, at with UNICEF and WHO to determine Shabelli. Contact was also made current and proposed levels of assistance. in Dr. Foster's WHO Assignment Background in'formation is recorded For of 20 April-12 May, 1978 (WHO EM/SOM/SPI/OO2/VA). Report 7 sections and 2 addendums: clarity this report is divided into iII Epidemiology IV Program Management V Vaccines and Cold Chain VI Mogadishu Program VII Middle Shabelli Program VIII Lower Shabelli Program IX Conclusions X Recommendations Addendum I Mogadishu Assessment Addendum II Jowhar Assessment II EPIDEMIOLOGY is to reduce morbidity and mortality The goal of'all EPI Programs at risk. of potent vaccines to 'populations through administration at risk within the the diseases and age groups most To identify of disease epidemiology is Somali population, better definition the. program on disease. also required to monitor.effect.qf inunerstanding -Since the. Maj .1978 report. .s.gnlifican't'progress has been.achieved by the Smallpog Eradication measles epidemiology 42 outbreaks of In a superb study Kriz followed up Program. District of Lower Juba. measles with 910 cases in Jamame Village Lower Juba­ Measle6 Morbidity and Mortality Jamame Investigation by Kriz:., " '" • ' .Distrib"Cumul.ative Deaths," ~ " Case" ""Fatality." • Total Cases..' " "'.% Distribution' ,-° a- Age ."~~ 0. 5.6 " .. .,56 0. 14.. ... 51.8 2 ' .I.4 144 .. 15,8. 3 65.9 ' 2 " 1.5 4 134 *1K.7 0.9 24.1 90 2 5-9 219 0" 0.0 49 5.4 95.4 10-14 0. 0.0 15+ 42 .4.6 100 9 1.0 Total 910 of the measles associated mortality As Jamame is a food surplus area, a-minimum estimate of national mortality. 1% probably represents population would estimate 8000 Extrapolating this 'rate to the entire -3- Measles associated deaths annually for Somalia. Another measure of measles impact on health isto quantify complications by age. Measles Complication Jamame District, Lower Juba­ Age.. .. .. .Cases:5 ,' ..... .No, iarhhes%-.O.''... Marasmus Blindness 51. "I 63 3" 6.. 0 17 , "101. 38 38 5'. 5 0 2 :170 70 41 18 1b 3 1.8 3 144 65 48 11 8, ". .7 4 134 56 42 4 3 1 .8 5'9 219 85 39 12 .5 1 .8 10-14 . .49 11 .22 2 ' 4 . 15" . 42 .2 . 5 2 5 Total'. .'91o3 .".39. 4i... 5. 6 . .7. Morbidity and iort'"ity'&re largely :imiled to polionde 5 Age of.infection varies with population density and with probability of exposure to other population groups. 1922 mea'sles cases investi­ gated in1979 by Smallpox Rash Fever Surveillance were analyzed as to age distribution. Age Distribution of 1922 Measles Cases detected by Smallpox Rash Fever Surveillance: Age No. % Cumulative I 1 13 '6. 0.6 1 147 7.6 8. 2 255 13.3 21:.5 4" 210 10.9 42.6'i , " 5 145 7.5 50.2 6 126 6.6 56.8 .7 88 4.6 61.4. " 8 13 5.9 67.3 9 55 . 2.9 70.2 10-14 293 15.2 85.4 15-19 145 7.5 92.9 19+ 136 7.1 100.00. -4- Analyzing this data by Region and population density showed an expected inverse relationship between age of infection and population density. Median Age of Measles Infection by Region . Region Cases"Media'Ae'6f'1fectionPopulation density oaishu T 3 Lower Shabelli 221 3 Middle Shabelli 273 4 Bay 698 5 Galbeed 342 '6 Sannag 111 12. Togdher 119 12 In Jamame median age of infection among nomads, 7 is significantly higher than among the settled populations. In a.seperate study by Miner, filter blood specimens were collected from three groups of children and were measured for measles HI antibody., evidence of previous measles infection. Age Specific Measles HI Antibody among Urban, Rural Settled, and Nomadic Somalis: Urban Rural Settled Nomadic Age No. No %+ No %4 1 29 1 3 20 1. 5 15 0 0 1 25 0 0 21, 5 24 14" 3 21 2 19 2 11 19 11 . 58 10 1 10 3 9 4 44 22 18 82 12 5 42 4 141 77 17 . 14 82 16 9 56 This data adds support to the later measles infection among nomads. From a program perspective, the above data has clear implications. I. Mortality is associated with a low age of infection 2. Low age of infection occurs populations. primarily in settled 3. Maximum program inpact on measles will occur when .vaccine is targeted to high density populations. The biggest deficiency in.EPI Epidemiology is that of Neonatal Tetanus. Studies by Aden and Birk demonstrated very high rates of Neonatal Tetanus, Further studies by McElroy failed to confirm neonatal tetanus as a major cause of mortality. Systematic studies of neonatal tetanus are a high program priority. -5- VI Program Management: Somalia will require direct Effective implementation of EPI in all levels of activity. As vaccinations central supervision of programs, out by at least three seperate operational will be carried Assignment of specifiG close coordination will be essential. be and supervisory responsibility will individual coordination detailed information each of the following program areas, required for course for program managers provided in the WHO EPI training will be Manual (Syria October 1979) and the WHO EPI Surveillance Disease Repair Cold Chain-Equipment Monotiring and Vaccine Monitoring and Supply Training Supervision, Field Collection Program Evaluation-Monthly Data Assessment Transport . Health'Education." . V Vaccinetand'Cold-Chain: are currently provided EPI vaccines for-Somalia EPI programs All ordered and projected are summarized by UNICEF. Vaccines supplied, in Appendix I. A. Ordering: . ected of.vaYcci,ne usage ;drnventor Current i6nitoring absence in.the coul6iry bf needs, needs improvement: The'current points out.the need to.strengthen any in date tetanus tox6d be possible to of vaccines. Only then will it central monitoring the build up of excessive match tupply with need and prevent inventories. B. Vaccine'Clearance: lost on entry, one of vaccine to Somalia have.been Three shipments to delayed notification inappropriate freezing and two due due to clearance remains a priority., and clearance. Attention to rapid C. CentralStorageof'VaCCine: are stored in a new WHO supplied Poliomyelitis and Measles'vaccines was routine was present in the freezer nor freezer. No thermometer ice and vaccine at carried out. The presence of pooled monotiring at least one major meltdown. the bottom of the freezer indicates -6- refrigerators in three overloaded unmonitored Mogadishu. ' !" DPT and BCG are stored MCH refrigerators in and at various WHO thermometers at EPI Headquarters were absent at all sites. Thermometers and monitoring monitoring of temperatures were distributed and daily (instorage) sites. was initiated in all central refrigeration cold room is kept in the central store Tetanus Toxid (outdated) at 25 degrees centigrade. July, 1979 Inventory of Vaccines at Headquarter Expiration Date Doses Temperature Lot Vaccine, Location 1981 6400 -20C 45B34 January, HQ freezer June, 1981 30000 Measles M57B34 980 2460 -20C S122A4 February,l HW freezer Sept 1979 6275 Poliomyelitis 56250 50000 S132A May 1980 HQ and MCH 1979 39000 DPT .