1998 Annual Report
EXPANDED PROGRAMME ON IMMUNIZATION

MISSION

To Eradicate, eliminate or reduce diseases to the lowest levels possible through sustained immunisation of all susceptibles as an essential component of Primary Health Care.

Introduction

Immunisation of the vulnerable population has remained a priority health programme of the Governments of the English-speaking Caribbean and Suriname. This has been exemplified by the resolution made by the august body of Health Officials of CARICOM to eliminate rubella and congenital rubella syndrome by the year 2000. Policy decisions have been implemented in support of the EPI programme, and the development of national infrastructure in response to local epidemiology of diseases.

Immunization Coverage

The average coverage rates for all 19 countries was: DPT 90%, OPV 90%, MMR 89%, and BCG 97%. Over 90% of the infant vaccinations in the countries are given by the public health sector through their network of clinics. Vaccination figures from the private sector are routinely collected from the private practitioners in most countries.

Figure 1

Immunization Coverage % for selected Antigens 1996-1997
English speaking Caribbean and Suriname

 The average coverage of all countries has not changed significantly, but some countries such as Grenada have increased coverage while Jamaica has decreased the MMR coverage by eight percent (8%).

Figure 2

Five countries still have rates between 80-90%. The immunisation coverage ranged from 85% to 100% for DPT and that for MMR being 78% to 100%. Seven of the 19 countries accomplished coverage rates of 100% with DPT and TOPV, and four for MMR vaccines. There are pockets of low coverage occurring in remote rural and dense urban areas in the larger countries, such as Belize, Jamaica, Trinidad and Tobago, and Suriname. Solutions to increase low coverage have been identified for implementation in most countries.

Introduction of Haemophilus Influenzae Type B (Hib) and Hepatitis B. Vaccines (cmcs)

With the availability of more safe and efficacious vaccines, our countries have been challenged to broaden the vaccination focus beyond the present nine diseases, and to include Haemophilus Influenzae type B (Hib) and Hepatitis B vaccines. Six countries have presently included Hib vaccine in the infant schedule, while five have included hepatitis B. Four countries have proposed to introduce Hepatitis B vaccine in the infant schedule in 1999, while six will introduce Haemophilius Influenzae type B vaccine.

The surveillance system for reporting these diseases is in place for some of the countries. All countries are already reporting cases of Hepatitis B infection as part of the national weekly surveillance reports to CAREC. Hib infection reports to national level is occurring in nine (9) countries. These countries are reporting information on meningitis, while some have also included pneumonia and or septicemia. However regional surveillance has not yet been established.

Poliomyelitis eradication

There have been no new cases of poliomyelitis since 1982 in the English speaking Caribbean and Suriname. The surveillance system for Acute Flaccid Paralysis (AFP) has yielded since 1995, a total of 83 AFP cases, all have been discarded as non-poliomyelitis following a complete epidemiologic and laboratory investigation.

The expected rate of AFP cases is usually one case per 100,000 population of children less than 15 years of age. In 1998, 18 AFP cases of all ages were reported with a total of 398 sites from 19 countries reporting weekly. In 1997, a total of 16 cases were reported (a rate of approximately 0.6/100,000). Of the eighteen cases notified in 1998, ten (55%) were investigated in less than 48 hours. Guyana met all four criteria, with Trinidad and Tobago meeting three criteria, while Suriname met two. It is of major concern that only 55% of cases were investigated fully within 48 hours. Stool specimens were collected from 17 of the cases. The rate of regional AFP has been below expected level for 1997 and 1998 (Figure 3). Jamaica has consistently reported less than the expected number of cases.

Figure 3

Annual Rate of Acute Flaccid Paralysis(afp) Cases
English-Speaking Caribbean & Suriname
1988-1998*

Measles Eradication

Since 1991, the reporting system in countries increased from 468 to 620 sites in 1998, with additional private sector facilities now reporting to national units. Ninety-nine percent of these sites reported weekly for 1998. A total of 3,801 suspected measles cases were reported during the years of 1991 to 1998 (Figure 5). Two thousand nine hundred and six (2,906) cases were discarded as unknown, 7 cases were laboratory confirmed measles, and 57 cases were classified as clinically confirmed measles, and the remainder were discarded as rubella or dengue.

Figure 5

Classification of Suspected Measles cases 1991-1998
English speaking Caribbean and Suriname

In 1997, 1,022 suspected measles cases were notified, while in 1998, 512 suspected cases have been notified. The decrease in number of cases reported is apparently due to the ending of the rubella epidemics in Guyana and Belize. In 1998, the age range of reported suspected cases was one month to 56 years, of which 16% of the cases were less than one year and 36% were over 15 years. For 1998, of the 512 reported suspected measles cases, 362 were discarded without specific diagnosis (that is neither measles, rubella or dengue cases). One hundred (19%) of cases were confirmed rubella and 49 (10%) were confirmed as Dengue.

There was one laboratory confirmed case of measles imported from Germany into Jamaica. This was an 11 year-old child visiting from Germany. The child had been previously vaccinated against rubella, but not measles. The specimen was taken on day two of the rash and received at CAREC after 6 days. The result was available 5 days after receipt at the laboratory.

There have been steady improvements in the surveillance indicators between the years, 1993-1998 (Figure 7). At present, 99% of sites report weekly and 94% have complete investigation with adequate blood specimen. Ninety-six (96%) of cases in 1998 are investigated within 48 hours, and 47% of forms were fully completed in 1998, compared to 65% in 1997.

Figure 7

Distribution of Rubella cases 1995-1998*
English speaking Caribbean and Suriname

Rubella/congenital rubella syndrome eradication

Since 1995, outbreaks of rubella have occurred in Jamaica, Barbados, Trinidad & Tobago, Guyana, Belize, Cayman Islands and Suriname. So far, 522 cases have been confirmed in the MESS. ( Figure 8.) The surveillance system for congenital rubella syndrome (CRS) was introduced to countries and implemented in most of them. Since then over forty cases of CRS have been reported from seven (7) countries.

Figure 8

Distribution of Rubella cases
1995-1998*
English speaking Caribbean and Suriname

The major rubella outbreak this year (1998) occurred in Suriname. Forty percent (40%) of the suspected measles cases were from Suriname and 44% of their cases were confirmed as rubella. In response to the increased rubella activity the Ministry of Health initiated rubella vaccination firstly, of females between 15 to 40 years, and later males were included.

From the Measles Elimination Surveillance System (MESS) database one hundred rubella cases have been confirmed in 1998, and Suriname accounted for 90% of cases, while Belize and Guyana had 3% and 4% respectively. The three cases in Bahamas were from one to five months of age and were babies with CRS

The age distribution of the rubella cases revealed that 25% were less than 15 years of age, 34%were in the age group of 15 to 24 years, and 41% were over 24 years of age. The male to female ratio was approximately 2:1.

This reflects the pre-pubertal rubella programme for girls in Suriname. A similar picture was seen during the increased rubella activity in Barbados and Jamaica.

The Ministers responsible for Health in the CARICOM community resolved on April 21, 1998 that every effort will be made to eliminate Rubella and prevent the occurrence of new cases of Congenital Rubella Syndrome (CRS) in the Caribbean Community by the end of the year 2000.

Rubella mass campaigns have been completed in three (3) countries so far, four (4) more are conducting their campaign, while the others will be conducted in 1999. A PAHO working group was convened in November, 1998 to develop guidelines for rubella and CRS surveillance. The working group felt it was not necessary to develop a new surveillance system specifically for rubella. So a combined surveillance system, which will be capable of detecting circulation of both measles and rubella viruses, was proposed. The CRS surveillance guidelines were reviewed and a sensitive, yet relatively simple CRS surveillance system was proposed for the countries.

Adverse Event Surveillance

Draft guidelines developed by PAHO for implementing a surveillance system for adverse events, following immunisation, have been adopted by some countries. Although many Caribbean countries had already developed such surveillance systems they were reporting in an ad hoc fashion. They are now benefiting from improvements and fine-tuning.

Vaccine and Logistics Procurement

Most of the countries were able to enjoy a steady supply of vaccines, syringes and needles in 1998. All countries have been purchasing their public sector vaccines through the PAHO/EPI Revolving Fund. This fund is also the source of some of the vaccines used by the private practitioners in most countries.

Fifteenth Caribbean EPI Managers’ Meeting

The Fifteenth Meeting of the Caribbean EPI Managers was held in St. Georges, Grenada from 16-18 December 1998. The meeting was attended by 70 health officials from 20 countries of the English- speaking Caribbean, Aruba, Bonaire, St. Maarten, Haiti, and the French Departments of Guadeloupe and Martinique. Also present were representatives from the Laboratory Centre for Disease Control (LCDC), Ottawa, Canada, the United States’ Centers for Disease Control and Prevention (CDC), Atlanta, the Department of Health of the United Kingdom, PAHO’s Caribbean Epidemiology Centre (CAREC), UNICEF, The Children’s Christian Fund(CCF), as well as technical staff from PAHO’s Special Program for Vaccines and Immunization (SVI).

The main objectives of the meeting were:-

Surveillance award

An annual Surveillance award was established to recognise countries that have performed outstandingly in their surveillance component of the program during the previous year. The award is based on two main criteria: on time reporting and percentage of sites reporting, and the analysis was based on data received at CAREC.

For 1998, the country receiving the Award was Anguilla. Trinidad and Tobago and the Cayman Islands received citations for second and third place.

Conclusion

The Immunisation programme in the countries including other vaccines being introduced in the primary schedule illustrates the commitment of Governments and health workers to agreed strategies and goals. Eradication of poliomyelitis and the interruption of measles transmission, as well as the elimination of Rubella and Congenital Rubella Syndrome (CRS) will present many challenges to public health practitioners in the region. However, special effort will be made to implement the activities of the rubella mass campaign, and so achieve the proposed goal.

Acknowledgement

Caribbean Epidemiology Centre
16-18 Jamaica Boulevard, Federation Park
P.O. Box 164, Port of Spain
Republic of Trinidad and Tobago
Tel: (868) 622-4261, Fax: (868) 622-2792
E-mail: postmaster@carec.paho.org

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