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PubMedDate not supplied

Re-evaluation of the basic procedures involved in the storage of measles vaccine in public health units of the municipality of Niterói, State of Rio de Janeiro, Brazil.

Four years after the first visit seventeen public health units were visited again and evaluated as to standards of storage recommended by the Brazilian Immunization Programme. In 100% of the units, refrigerators and proper inside location of vaccines in the refrigerator were adequately or regularly maintained and checked, respectively. However, when control of temperature was checked, only 64.7% presented adequate storage conditions. In 94.1% of the units, health workers complained of lack of immediate technical support in emergency situations. In 55.2% the titers vaccine samples of were under the minimal recommended potency. It is necessary that the factors concerning the cold chain be continually evaluated so that the quality of the vaccines that will be used is not affected.

Brazil↗

PubMed2002

Effect of triethylamine on the recovery of selected South American alphaviruses, flaviviruses, and bunyaviruses from mosquito (Diptera: Culicidae) pools.

We evaluated the effect of triethylamine (TEA) on the recovery of infectious virus from pools of mosquitoes for two South American alphaviruses (eastern equine encephalomyelitis and Venezuelan equine encephalomyelitis subtypes IIIC and ID), one flavivirus (Ilheus) and two bunyaviruses (Mirim [Guama group] and Itaqui [group C]). Mosquitoes were inoculated intrathoracically with virus, held for 7-10 d at 26 degrees C, and handled under one of four regimens before testing for the presence of virus by plaque assay. Mosquitoes were killed by freezing at - 70 degrees C for 3 min and tested immediately for the presence of virus; killed by freezing at -70 degrees C for 3 min and then held at room temperature for 1 h before testing for the presence of virus; anesthetized with TEA and assayed immediately for the presence of virus; or anesthetized with TEA and then held at room temperature for 1 h before being assayed for the presence of virus. For each of the viruses tested, viral titers in mosquitoes anesthetized with TEA were similar to those in mosquitoes killed by freezing at-70 degrees C. Likewise, there was no significant difference in viral titers in mosquitoes anesthetized with TEA and held at room temperature for 1 h or in mosquitoes frozen at -70 degrees C and held at room temperature for 1 h before being processed for virus by isolation. Triethylamine is advantageous for the handling of mosquitoes in a field environment. The elimination of the need for a cold chain, without compromising virus recovery, increases the feasibility of conducting research projects requiring the isolation of live virus from mosquitoes in remote tropical environments.

Animals↗

PubMed2001

Measles epidemiology and outbreak investigation using IgM test in Laos.

Following the Pan American Health Organization (PAHO) recommendation on measles elimination, the Western Pacific Region of WHO (WPR) is emphasizing accelerated measles control programme especially since the achievement of polio eradication in WPR in 2000. This includes upgraded surveillance and mass measles vaccination campaign for children aged 9 months to 4 years. However, there are limited scientific evidences supporting the feasibility of this programme in Laos. To examine measles elimination feasibility in the country, we conducted measles outbreak investigation using immunoglobulin M (IgM). From March 1999 to March 2000, we conducted 7 outbreak investigations. At the outbreak sites, we examined clinical manifestations of cases and collected individual data. About five blood samples were drawn from each outbreak, and IgM antibodies to measles were tested. Of 7 investigated outbreaks, 5 were confirmed as measles, one was chickenpox, and one occurred in the inaccessible area due to flooding. In a village of high land Lao, blood drawn was refused. Of 185 cases, 64 (34.6%) cases were immunized, and 110 (59.5%) were unimunized. The estimated vaccine efficacy is 67.9%. The number of measles cases among school-aged children was 74 (40.0%), which represented 2.5% of the total population in investigated villages. Our findings showed various difficulties of the surveillance and the limited outcomes of mass measles vaccination campaign under the accelerated measles control programme by WPR. Efforts to improve cold chain as well as increasing routine immunization coverage must be the priority of measles control.

Antibodies, Viral↗

PubMed1990

Crash of the immunization program: consequences of a totalitarian approach.

India's Universal Immunization Program, which was to cover a population of more than 90 million pregnant mothers and 83 million infants living in more than 575,000 villages during 1986-90, has failed dismally. The coverage has been less than one-fifth of the requirement in more than half of the population. The situation in most third world countries, which have even weaker political clout and weaker health service infrastructures, is even more catastrophic. From a purely public health standpoint, the disaster was inevitable. No efforts were made even to define the problem of the six immunizable diseases; there was no question of understanding their natural history; the efficacy of the vaccines used was not well-known; the cold chain, which is meant to retain the potency of the vaccines at the time of inoculation, frequently broke down; there was confusion about the dosage; and even where the program is most successful, ecological conditions will erode much of the benefits from immunization. That such a technocentric program was imposed on the peoples of the third world by their governments was bad enough; even more frightening is that these countries were persuaded to follow the line developed in affluent countries by influential agencies such as UNICEF, WHO, the World Bank, the Rockefeller Foundation, and Rotary International. This is an awe-inspiring manifestation of the power of the affluent countries to impose their will on the weak and helpless peoples of the world. It is a bitter irony that UNICEF and WHO, which sponsored the famous global conference at Alma-Ata, should have lent their weight to a program that is the very antithesis of the Declaration. To embark on such a venture, the exponents had to ignore weighty scientific evidence that raised serious doubts about the program. They had to stoop to suppression of information, disinformation, and distortion of information. What is even worse, efforts will be made to erase this experience from memory, and similar efforts will again be made to launch such ill-conceived programs in the name of the welfare of the oppressed peoples of the world. Scholars who have concern for the oppressed must remain vigilant.

Female↗

PubMed1990

The effect of industrial handling on micronutrients.

The growing proportion of processed foods in the average daily diet in industrialized countries is considered as a challenge to the food industry, not only to provide more variety to the food assortment, but also to cope with high nutritional quality standards. Industrial handling of food therefore includes the monitoring of numerous operations and conditions from the agricultural source, through processing, packaging and distribution. Various types of food raw materials are processed by different kinds of technological treatments, the main objectives being to guarantee wholesomeness, taste, nourishment and convenience. New processing methods combined with the cold chain distribution reduce micronutrient losses to a certain extent. We shall examine some of the critical technological operations with regard to losses of vitamins and minerals in representative examples of foods like milk, leafy vegetables, potatoes, etc. and compare the classical food preservation with more modern food handling. With the increasing demand of pre-prepared fresh, refrigerated or frozen foods, the contribution of the maintained micronutrients is of interest, especially with reference to modern eating habits, i.e. lowering the total food intake and improving the nutrient density in the normal diet plan.

Animals↗

PubMed2003

Short report: assessing field vaccine efficacy for measles in famine-affected rural Ethiopia.

Measles is a major cause of mortality in complex emergencies. Both high vaccination coverage and vaccine efficacy are required to prevent major epidemics of measles in such situations. Evaluation of field vaccine efficacy is a critical but underutilized component of program monitoring in emergencies, and is particularly important in rural areas where the integrity of the cold chain is difficult to guarantee. In July 2000, we evaluated the field vaccine efficacy for measles vaccination by comparing the incidence of cases in vaccinated and unvaccinated groups during a two-stage cluster survey of 563 children in Ethiopia. Approximately 30% of the measles cases occurred in vaccinated children. Estimated field vaccine efficacy for measles was 66.9% in children 9-36 months old. The finding of a field vaccine efficacy for measles less than 80% warrants formal assessment of measles vaccine efficacy, particularly in famine emergencies where measles is associated with a high case fatality rate.

Age Factors↗

PubMed2001

Monitoring of microbial hazards at farms, slaughterhouses, and processing lines of swine in Korea.

This study was executed to investigate microbiological hazards at swine farms, slaughterhouses, dressing operations, and local markets for the application of the hazard analysis critical control point system in Korea by analyzing total aerobic plate count (APC) and presence of pathogens. Six integrated pig farms and meat packers were selected from six different provinces, and samples were collected from pig carcasses by swabbing and excision methods at the slaughterhouses, processing rooms, and local markets, respectively. APCs of water in water tanks were relatively low, 1.9 to 3.1 log10 CFU/ml; however, they were increased to 4.6 to 6.9 log10 CFU/ml when sampled from water nipples in the pigpen. APCs of feeds in the feed bins and in the pigpens were 4.4 to 5.4 and 5.2 to 6.7 log10 CFU/g, respectively. Salmonella spp., Staphylococcus aureus, and Clostridium perfringens were detected from water and feed sampled in pigpens and pigpen floors. S. aureus was the most frequently detected pathogenic bacteria in slaughterhouses and processing rooms. Listeria monocytogenes and Yersinia enterocolitica were also detected from the processing rooms of the Kyonggi, Kyongsang, and Cheju provinces. Even though APCs were maintained at the low level of 3.0 log10 CFU/g during slaughtering and processing steps, those of final pork products produced by the same companies showed relatively high numbers when purchased from the local market. These results indicated that the cold chain system for transporting and merchandising of pork products was deficient in Korea. Water supply and feed bins in swine farms and individual operations can be identified as critical control points to reduce microbiological hazards in swine farms, slaughterhouses, and processing plants.

Abattoirs↗

PubMed2006

Microflora of minimally processed frozen vegetables sold in Gaborone, Botswana.

Two hundred samples of minimally processed, frozen, and prepacked potato chips, peas, corn, and a variety of combined vegetables from supermarkets in Gaborone, Botswana, were examined microbiologically. Determination of aerobic mesophilic plate count, aerobic psychrotrophic plate count, lactic acid bacteria, yeasts and molds, coliforms, Listeria spp., and Staphylococcus aureus were done. Chips had the lowest mean log values for all of the microorganisms enumerated except yeasts and molds. The mean log values for single vegetables ranged from 3.6 to 9.1, 3.4 to 8.9, 2.9 to 5.6, and 2.1 to 6.5 log CFU/ g aerobic mesophilic plate count, aerobic psychrotrophic plate count, lactic acid bacteria, and yeasts and molds, respectively. The microbial profiles of peas and corn were almost similar (P < 0.001). The mean values for combined vegetables were clustered within 4.6 and 5.4 and 4.2 and 5.2 log CFU/g aerobic mesophilic plate count and aerobic psychrotrophic plate count, respectively. All of the vegetables had a coliform population distribution ranging from 0 to < 10(4) most probable number per g. The predominant gram-negative bacteria isolated included members of Enterobacteriaceae and Pseudomonaceae (86.2%). Escherichia coli was not detected in all of the samples. The organisms isolated included those responsible for spoilage in frozen vegetables, namely Pseudomonas, Klebsiella, Corynebacterium, lactic acid bacteria, and Flavobacterium. The predominant lactic acid bacteria were Lactobacillus spp. (55.9%). Other spoilage organisms were yeasts, and Cryptococcus spp. (55.4%) was predominant. Pathogens, namely Listeria monocytogenes, were also isolated at a rate of 2 to 10%, of which 4% was from corn, 2% each from peas and country crop, and 10% from stir-fry. Bacillus cereus was also isolated and accounted for 7.7% of the microorganisms from corn. S. aureus was isolated from all of the vegetables. Enterotoxigenic strains were from corn, peas, mixed vegetables, and stir-fry, and all of them produced enterotoxin A. In addition, the isolates from stir-fry vegetables also produced enterotoxins B and C. The study reveals the presence of pathogens and emerging opportunistic pathogens in the ready-to-use or ready-to-eat vegetables. If E. coli is the only indicator for safety and acceptability, consumers may be exposed to foodborne diseases. Inclusion of other groups as indicator organisms is suggested. Retailers are urged to invest in standby generators to maintain the cold chain.

Bacteria↗

PubMed1999

Home delivery of heat-stable vaccines in Indonesia: outreach immunization with a prefilled, single-use injection device.

Extending immunization coverage to underserved populations will require innovative immunization strategies. This study evaluated one such strategy: the use of a prefilled, single-use injection device for outreach immunization by village midwives. The device, UniJect, is designed to prevent refilling or reuse. Stored at ambient temperatures for up to 1 month in midwives' homes, vaccine-filled UniJect devices were immediately available for outreach. Between July 1995 and April 1996, 110 midwives on the Indonesia islands of Lombok and Bali visited the homes of newborn infants to deliver hepatitis B vaccine to the infants and tetanus toxoid to their mothers. Observations and interviews showed that the midwives used the device properly and safely to administer approximately 10,000 sterile injections in home settings. There were no problems with excessive heat exposure during the storage or delivery of vaccine. Injection recipients and midwives expressed a strong preference for the UniJect device over a standard syringe. Use of the prefilled device outside the cold chain simplified the logistics and facilitated the speed and efficiency of home visits, while the single-dose format minimized vaccine wastage.

Adult↗

PubMedDate not supplied

[Establishment of a blood transfusion center at Kabul (Afghanistan)].

Recent events concerning blood transfusion (BT) have led to the number of BT being drastically reduced and to more rigorous checking of blood donations before their use for transfusion. Very few developing countries have been able to set up BT organizations that are both self-sufficient and capable of ensuring a high quality of blood testing. A central blood bank (CBB) was set up in Kabul (Afghanistan) during the 1980s. From 1992 onwards, its activities were curtailed due to the political turmoil, lack of funds and the fact that no blood collection policy was being implemented. A partnership between a development aid agency (Avicen), French public institutions and the local authorities has resulted in the rebirth of this CBB by the injection of financial resources and technical and scientific expertise. An independent committee of BT specialists was responsible for assessing the scientific validity and ethical acceptability of the project. In 1996, the objectives of the project, which had been in operation for one year, were achieved as far as the renovation of the laboratories was concerned. Work has focused mostly on setting up a proper cold chain and on training laboratory technicians in standard biological methods for testing blood from donors (blood group, HIV screening, Ag Hbs, HCV and syphilis). However, due to the shortage of blood donors, it has been difficult to set up a minimum blood bank stock. The results of the first biological tests carried out on the blood of the first 1,281 donors have made it possible to define an appropriate, detailed policy for preventing and controlling the main risks of infection from BT, involving routine testing for HIV, Ag HBs and HCV (0.3% prevalence). BT is a major component of any health care system and it must be reconstructed. The measures proposed here are long-term and require the ongoing participation of all those involved in this project including the local authorities and sources of financial support.

Adult↗

PubMed1998

Efficacy of two dose measles vaccination in a community setting.

OBJECTIVE: To compare the efficacy of two dose and single dose measles vaccination in a community setting. DESIGN: Two community ICDS blocks with populations of 8990 and 8550 children below 12 years of age were selected. Block A had 1560 children between 9 mo to 1 year of age and Block B had 1380 children between the age of 9 mo to 1 year. METHODS: All eligible children between 9 mo to 1 year of age were given measles vaccination in October 1994. Only the children in Group A were given a second dose of measles (as MMR) in April 1995; six months after the first dose. A survey was undertaken from January 1996 to April 1996 to clinically evaluate the number of cases of measles in both these blocks. RESULTS: In Block A 3 children developed measles, whereas in Block B, there were 16 cases of measles (p < 0.01). All other parameters in both groups, e.g., cold chain maintenance were similar. CONCLUSION: This study supports the superiority of two dose measles vaccination given at an interval of 6 months over a single dose measles in a community setting.

Case-Control Studies↗

PubMed1999

Vaccine storage in the community: a study in central Italy.

Maintaining the vaccine cold chain is an essential part of a successful immunization programme, but in developed countries faulty procedures may occur more commonly than is generally believed. A survey was conducted in a health district in central Italy to assess the methods of vaccine transportation and storage. Of 52 primary vaccination offices inspected, 39 (76.5%) had a refrigerator for vaccine storage but only 17 (33.3%) kept records of received and stored doses. None of the seven main offices selected for monitoring had a maximum and minimum thermometer and none monitored the internal temperature of the refrigerator. Moreover, other faulty procedures, such as the storage of food and laboratory specimens in vaccine refrigerators and the storage of vaccines on refrigerator door shelves, indicated that the knowledge and practice of vaccine storage and handling were often inadequate.

Documentation↗

PubMed2000

Safety of immunization injections in Africa: not simply a problem of logistics.

In 1995, the WHO Regional Office for Africa launched a logistics project to address the four main areas of immunization logistics: the cold chain, transport, vaccine supply and quality, and the safety of injections in the countries of the region. The impact of this logistic approach on immunization injection safety was evaluated through surveys of injection procedures and an analysis of the injection materials (e.g. sterilizable or disposable syringes) chosen by the Expanded Programme on Immunization (EPI) and those actually seen to be used. Re-use of injection materials without sterilization, accidental needle-stick injuries among health care workers, and injection-related abscesses in patients were common in countries in the WHO African Region. Few health centres used time-steam saturation-temperature (TST) indicators to check the quality of sterilization and, in many centres, the injection equipment was boiled instead of being steam sterilized. Facilities for the proper disposal of used materials were rarely present. Although the official EPI choice was to use sterilizable equipment, use of a combination of sterilizable and disposable equipment was observed in the field. Unsafe injection practices in these countries were generally due to a failure to integrate nursing practices and public awareness with injection safety issues, and an absence of the influence of EPI managers on health care service delivery. Holistic rather than logistic approaches should be adopted to achieve safe injections in immunization, in the broader context of promoting safe vaccines and safety of all injections.

Africa↗

PubMed1999

Epidemiological characteristics of poliomyelitis in Delhi, 1997.

OBJECTIVE: To describe the epidemiological characteristics of poliomyelitis in Delhi in 1997 after four consecutive statewide immunization campaigns with oral polio vaccine (OPV). METHODS: Stool samples were collected from 158 cases of acute flaccid paralysis (AFP) along with their age, sex, residential address, immunization history and dates of onset of paralysis, reporting and investigation. The samples were processed for isolation of polioviruses. In addition, historical data on vaccination coverage surveys and OPV testing were reviewed. These data were analyzed to understand the epidemiological patterns of poliomyelitis in Delhi. RESULTS: Of 158 cases of AFP, about 23% were investigated within 2 days of onset of paralysis. Two samples each were collected from 97 (61%) cases, and one each from the remaining cases. Detection of 158 cases of AFP gave an incidence of 1.34 per 100,000 population. About 36% (57/158) of AFP cases excreted poliovirus, mostly (53/158) wild poliovirus. Of the wild poliovirus isolates, 72% (38/53) and 25% (13/53) were serotypes P1 and P3 respectively; 2 isolates were P2. Almost 95% (146/154) of AFP cases and all the laboratory confirmed cases (excreting wild poliovirus) occurred in children below 5 years of age. Only one-third of AFP (55/158) or laboratory confirmed cases (18/53) had received 3 or more doses of OPV before onset of paralysis. About one-fourth of cases in both the categories were totally unvaccinated. AFP cases occurred round the year but peaked in November-December. Peaks were always observed during July-August in the past. The cases were widely scattered without any obvious clustering in any locality. CONCLUSIONS: Poliomyelitis has declined substantially in Delhi. The study underscores the need for further efforts to improve vaccine coverage levels, AFP surveillance, and cold chain maintenance to achieve the complete interruption of transmission.

Child↗

PubMed2000

Synthesis of lipopolysaccharides in the bacterium Yersinia pseudotuberculosis: effect of the pVM82 plasmid and growth temperature.

The composition and structure of lipopolysaccharides (LPS) of three isogenic strains of Yersinia pseudotuberculosis serovar O:1b (without plasmids (82-) and with plasmids pVM82 (82+) or p57 (57+)) grown at 8 or 37 degrees C were studied by chemical and immunochemical methods, SDS-polyacrylamide gel electrophoresis, and 13C-NMR spectroscopy. At the lower temperature, the (82-) and (82+) strains synthesized S-form of LPS with similar structure characterized by high acylation and immunochemical activity. On the other hand, LPS of the (82+) strain had shorter carbohydrate chains than LPS of the (82-) strain. The contents of LPS were decreased in cells of the plasmid-free strain grown at the higher temperature. LPS isolated from these cells were of the R-form and had low acylation and immunochemical activity. Total LPS content in cells of the (82+) strain did not significantly depend on the growth temperature. LPS of the warm variant of these bacteria contained a polysaccharide fragment and had moderate immunochemical activity. The cells of the (57+) strain at both growth temperatures had low LPS contents and produced LPS of low acylation without O-specific chains (cold variant) or containing O-polysaccharide with low polymerization degree (bacteria grown at 37 degrees C). The data indicate that in the absence of the plasmids, LPS synthesis is encoded by the chromosomal genes in pseudotuberculosis bacteria. Expression of the genes involved in LPS synthesis is regulated by the temperature of bacterial growth. Genes responsible for temperature-dependent regulation of LPS biosynthesis are located on chromosomal DNA. The pVM82 plasmid includes two gene groups; one group is localized in a 57-mD fragment of DNA and inhibits LPS synthesis, suppressing temperature-dependent regulation of the synthesis. The genes located in a 25-mD fragment of the pVM82 plasmid are de-repressors of the 57-mD fragment, and they restore the ability of pseudotuberculosis bacteria to synthesize relatively long LPS at both growth temperatures.

Electrophoresis, Polyacrylamide Gel↗

PubMedDate not supplied

Poliomyelitis in India: past, present and future.

In that they were made in temperate countries, most of the studies on poliomyelitis may not apply in sub-continent of endemic infantile paralysis. This review brings together data on polio in India, to present any changes which may have occurred since 1940. Only about 2% of children with polio die in the acute illness; about 95% of all cases have paralysis of one or both legs. In lameness surveys the adjustments for deaths and for arm paralysis are unnecessary and inflate the prevalence. Surveys suggest that prevalence has risen, but there may be other explanations for the figures. Around sentinel centres with effective cold chains, prevalence has decreased rapidly. The figures of the National Baseline Prevalence survey are examined. There are few cases of provocation, but a new phenomenon of aggravation by unnecessary intramuscular injections given to children with fever has been described. Such unnecessary injections are thought to be the cause of more severe paralysis in about 45% of cases and of converting a non-paralytic attack into paralysis in another 30% of the perhaps 200,000 cases in India each year. Aggravation is thought to be caused by a mechanism similar to the effects of physical activity. It is possible that massage might have a similar effect. Abscesses or their treatment may precipitate paralysis. The median age of paralysis fell by almost a half from about 2 yr to 1 yr, but may now have risen as many younger children receive vaccine. Rehabilitation has been neglected, with long lasting consequences. Assessment of disability should be based on need and not on current ability. Ethically, prevalence surveys should offer opportunity for immunization and rehabilitation. Prevalence of paralysis, numbers attending for rehabilitation and immunization have been analysed by gender and differences examined. The gender-gap widens with age after paralysis: there may be a high mortality among girls with paralysis. Past prevalence calculated from surveys might be seriously underestimated if many girls have died. The monthly pattern of polio was no different in epidemic years. Pulse immunization could be tried just before the seasonal rise each year. Difficulties of comparing vaccination schedules and the criteria for assessing the potency of vaccine are analysed. Paralysis among Indian soldiers in World War II suggests that adult cases may occur, but are not reported. Present investigations should concentrate on babies and adult cases. Research using virulent strains should be prohibited. The very low case-fatality rate suggests that many of the circulating viruses are of low virulence. The increasing proportion of cases with unnecessary injections just prior to paralysis might have caused the lower median age of paralysis, the severity of paralysis and at least part of the increasing prevalence of polio. The seasonal increases of polio might, in part, be a reflection of the injections given for fever caused by other infections. A national campaign against unnecessary injections for young children is urgently required. For children with fever, there is a strong case for postponing even DPT injections.

Adolescent↗

PubMed1978

The expanded program in immunization. Ghana's experience.

The expanded programme on immunization feasibility studies is currently running into its second year of operations. The objectives of the study are to test the possibility of increased coverage using both fixed centre and mobile field teams for the vaccination of children under the age of 2 years against measles, poliomyelitis, diphtheria, pertussis, tuberculosis and smallpox and also to test the immunological response to two doses of pertussis and two doses of oral polio. Reports so far indicate some success in the areas of training and manpower development as well as the development of the cold chain system which is considered to be the most important requirement for an efficient, expanded immunization programme. It goes without saying that the progress of the study has been marked by some technical, social and administrative constraints.

Child↗

PubMedDate not supplied

Current opportunities and future challenges in child health in Papua New Guinea.

Papua New Guinea (PNG) is at a crossroads in child health care. We know how to treat or prevent most of the diseases causing child and maternal mortality, but we are failing to deliver the services to where most of the people are dying. There is much to be learnt from early achievements in the development of health services in PNG. Between the 1950s and 1970s the infant mortality rate fell from 250-500 per 1000 livebirths to 77-100 per 1000 livebirths. This occurred predominantly because of an emphasis on public health programs and cost-effective standard treatment. Now the public health services have deteriorated, vaccine coverage is poor and health workers are not fully using the standard treatment resources available to them. The greatest academic and practical challenges facing medicine in PNG are to implement effective and consistent delivery of vaccines, and nutritional, basic curative and maternal care to remote or impoverished communities. The other unmet prerequisites for improvement in health status are that communities participate in and take some responsibility for their health care needs. There are now unprecedented opportunities for collaboration with international partners, churches, non-government organizations and community groups to achieve these goals. Specific key strategies in child health include the more widespread utilization of the 10-Step Checklist, adoption of some of the World Health Organization Integrated Management of Childhood Illness strategies, increased output of child health nursing training, improving vaccine delivery and cold-chain services, and new immunization strategies for acute respiratory infections. The National Health Plan 2001-2010, launched in August 2000, emphasizes the vital importance of public health; the need for greater access to quality health services; improving clinical skills among health workers at all levels; and cooperation between all interested parties. By 2010 the National Health Plan must be judged not on how good the plan seemed on paper, but on whether there was a measurable reduction in maternal and child mortality over the first decade of this century.

Child↗