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The economic crisis in Thailand in July 1997 had major social implications for unemployment, under employment, household income contraction, changing expenditure patterns, and child abandonment. The crisis increased poverty incidence by 1 million, of whom 54% were the ultra-poor. This paper explores and explains the short-term health impact of the crisis, using existing data and some special surveys and interviews for 2 years during 1998-99. The health impacts of the crisis are mixed, some being negative and some being positive. Household health expenditure reduced by 24% in real terms; among the poorer households, institutional care was replaced by self-medication. The pre-crisis rising trend in expenditure on alcohol and tobacco consumption was reversed. Immunization spending and coverage were sustained at a very high level after the crisis, but reports of increases in diphtheria and pertussis indicate declining programme quality. An increase in malaria, despite budget increases, had many causes but was mainly due to reduced programme effectiveness. STD incidence continued the pre-crisis downward trend. Rates of HIV risky sexual behaviour were higher among conscripts than other male workers, but in both groups there was lower condom use with casual partners. HIV serosurveillance showed a continuation of the pre-crisis downward trend among commercial sex workers (CSW, both brothel and non-brothel based), pregnant women and donated blood; this trend was slightly reversed among male STD patients and more among intravenous drug users. Condom coverage among brothel based CSW continued to increase to 97.5%, despite a 72% budget cut in free condom distribution. Poverty and lack of insurance coverage are two major determinants of absence of or inadequate antenatal care, and low birthweight. The Low Income Scheme could not adequately cover the poor but the voluntary Health Card Scheme played a health safety net role for maternal and child health. Low birthweight and underweight among school children were observed during the crisis. The impact of the crisis on health was minimal in some sectors but not in the others if the pre-crisis condition is efficient and healthy and vice versa. We demonstrated some key health status parameters during the 2-year period after the 1997 crisis but do not have firm conclusions on the impact of the economic crisis on health status, as our observation is too short and there is uncertainty on how long the crisis will last.
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PMID:Health impacts of rapid economic changes in Thailand. 1097 25

The 20th century has witnessed many important events in the control of infectious diseases that mostly affect children. In addition to the eradication of smallpox, the interruption of poliomyelitis transmission in many countries with a distinct possibility of its eradication by the turn of this century are some of the major achievements. Also, the rates of other vaccine preventable diseases such as measles, pertussis and diphtheria have gone down significantly. The discovery and use of vaccines have made it possible to save approximately 8 million deaths, annually. This is in addition to the reduction in millions of children's suffering and disability. It is now important to build on these gains through adequate utilisation of other vaccines e.g., hepatitis B, typhoid and Haemophilus influenzae type b that are currently available, but in limited use. But, a high level of coverage for any vaccination programme is a pre-requisite to witness the effective reduction of the specific disease against which child population is vaccinated. This paper reviews the coverage levels by surveys in the last 3 years. It has been observed that vaccination coverage levels are falling. Keeping the promises of immunising every child to fulfill his/her right is the need of the hour. To achieve this the major action points are: (a) The need for organising fixed immunisation sessions at the community, where low proportion of sessions are held; and (b) The need to improve demand generation activities where the coverage is poor despite better service availability at the community level. Therefore, the challenge for the next century is to make sure that the enormous impact of vaccines on the health and well-being of the population is maintained as well as expanded. Vaccines that effectively prevent rotavirus diarrhoea, pneumococcal pneumonia, menigococcal meningitis, if made available, could prevent deaths up to two million a year. Research efforts are currently under progress to develop new vaccines against malaria, tuberculosis, shigella-induced dysentery, and Esch coli-induced diarrhoea.
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PMID:Trends and determinants of immunisation coverage in India. 1101 38

In the first half of the 20th century, improved living conditions, preventive measures, vaccines and antibiotics led to a marked reduction in morbidity and mortality from infectious diseases. It was predicted that the conquest of all infectious diseases was imminent. However, 50 years later, in 1999, they were still the major cause of disease worldwide, and caused nearly one third of all deaths (a total of 55.9 million). The eradication of smallpox in the 1970s and the approaching eradication of poliomyelitis represent major achievements. The prevalence of measles, pertussis and tetanus neonatorum is also markedly reduced, but still 1.5 million children in developing countries die each year because of lack of vaccines. Malaria and tuberculosis are re-emerging. Tuberculosis and HIV/AIDS are the diseases with known aetiology that cause most deaths, altogether 5 million each year. Respiratory and gastrointestinal infections cause 6.5 million deaths annually. Infections in the immunocompromised host have become a "trade mark" of today's advanced medicine. Almost every year, new diseases related to new micro-organisms are described; over the last 30 years, approximately 40 new diseases/micro-organisms have been diagnosed. Among the best known are HIV/AIDS, peptic ulcer caused by Helicobacter pylori, Legionnaires' disease, borreliosis (Lyme disease), hepatitis C, gastroenteritis caused by rotavirus, and Ebola haemorrhagic fever. Antimicrobial resistance development of micro-organisms has become one of the major health problems worldwide; a number of preventive measures are being introduced.
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PMID:[Microorganisms strike back--infectious diseases during the last 50 years]. 1180 14

The Proceedings here reviewed are those of the meeting held in Geneva in October, 1983, which led to the establishment of the World Health Organization's Program for the Accelerated Development of New Vaccines. These papers reflect the state of the art in the development of vaccines for cholera, leprosy, pertussis, salmonella, shigella, dengue, foot-and-mouth disease, hepatitis B, herpes simplex, influenza, poliomyelitis, Chagas' disease, malaria, and schistosomiasis. The identification and isolation of epitopes and other antigenic fragments is presented, as well as considerations of mucosal immunity, antigenic determinants and antigenic variations, antigen presentation and T-cell activation, the use of anti-idiotypes as antigens, the development of recombinant viruses for use in vaccines, and the use of circumsporozoite antigens in the preparation of a malaria vaccine.
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PMID:New approaches to vaccine development. Proceedings of a meeting organized by the World Health Organization. Book review. 1222 27

Child survival in Cameroon is measured in the 1991 Demographic and Health Survey and found to be substantially improved. The survey includes a sample of 3871 women aged 15-49 years and a sample of 814 husbands. Community services data is also collected. Child mortality is reported as declining from 198 to 126 deaths per 1000 births during 1976-91. Infant mortality is shown to decline to 65/1000. Mortality of children aged 1-4 years is 66/1000. 79% receive prenatal care from some source, and 70% receive a dose of tetanus toxoid vaccine during pregnancy. A health professional is present at delivery for 64% of pregnant women. 52% of children aged 12-23 months have a health card, and 41% have tuberculosis, polio, diphtheria, pertussis, tetanus, and measles immunization. One in five still does not have any immunization. 62% of children with mothers who have at least a secondary school education are immunized. Diarrhea morbidity in the two weeks preceding the survey is 18% for children aged under 5 years. 9% have a cough and rapid breathing, and 23% have a fever. Child mortality among children aged 1-5 years is due to diarrhea (27%), malaria (23%), measles (27%), and respiratory infections (16%). Only 3% of children aged under 5 years has acute malnutrition. One in four are stunted, which reflects prolonged or chronic undernutrition. The total fertility rate is 5.8 children per woman, which is a 10% decrease from 1978. The lowest fertility is among women in the main cities of Yaounde and Douala (4.4 children) and among women with a secondary or higher education (4.5). Over 50% of women have sexual intercourse before the age of 16 years, and 50% are married before the age of 17 years. 50% of married women have their first child at the age of 19 years. Contraceptive usage is 16% among women in any union, of which 25% is use of a modern method. Only 1 in 25 women use an effective method, but this rate is double the rate in 1978. Total fertility would be 10% if unwanted fertility were avoided. Most men and women want large families.
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PMID:Improved child survival in Cameroon. 1228 22

The Lady Dufferin Fund, founded in 1885 in India, had by 1940 established 400 hospitals to alleviate diseases and mortality related to childbirth. After independence 2328 community health centers and 21254 primary health centers were created in the country. During 1974-94 more than 131,000 subcenters were set up and about 620,000 auxiliary nurse midwives (ANMs) had been trained. The Ministry of Health introduced four health prevention schemes in 1969: 1) immunization of children against diphtheria, pertussis, and tetanus; 2) immunization of pregnant women against tetanus; 3) prophylaxis of mothers and children against nutritional anemia; and 4) prophylaxis of children against blindness caused by vitamin A deficiency. As a result, infant mortality declined from 146/1000 live births to 74/1000 in 1993; but maternal mortality still stayed around 4-5/1000. In 1993 an estimated 117,356 maternal deaths occurred out of a total of 26,057,000 births, equalling 4.5 deaths per 1000 live births. The main causes of maternal deaths are hemorrhage, anemia, abortion, toxemia, and puerperal sepsis. Only about 411 first referral units in community health centers are functioning properly. Prenatal care of mothers includes the administration of tetanus toxoid and iron-folic acid tablets. However, the prenatal coverage reached only about 50% of mothers; and the coverage was only 21.4% in Bihar, 23.8% in Nagaland, 29.3% in Rajasthan, and 29.6% in Uttar Pradesh. In these areas administrative inefficiency is widespread with nonavailability of essential drugs for malaria, infections, sepsis, dysentery, and colds. During 1992-93 the rate of hospital deliveries ranged from 6.1% in Nagaland to 88.4% in Kerala, with a national average of only 25.6%. 71% of deliveries in rural areas and 30% in urban areas were conducted by untrained assistants. Although there are 450 ANM training schools in the country, the level of training has deteriorated. The major causes of infant deaths are respiratory infections and diarrhea, responsible for 13.5% and 6.9% of mortality, respectively. Severe malnutrition and inadequate vaccination are other major causes of child deaths and morbidity.
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PMID:Maternal and child health in India: a critical review. 1229 Sep 61

This document presents an interview with Dr. Anthony Fauci on the development of a new generation of vaccines to prevent and possibly eradicate a legion of deadly diseases ranging from tuberculosis to AIDS. Infections that have caused major devastations in the world today include tuberculosis, malaria, schistosomiasis, filariasis, pneumococcal pneumonia, influenza, AIDS, and Ebola. Agencies should be making sure that the basic research base in microbiology, immunology, antimicrobials, and vaccinology is at the very highest level. The integration of research efforts between countries depends on collaboration between the investigators of home countries with foreign investigators. Among new developments in vaccinology are an acellular pertussis vaccine for pertussis/whooping cough (an extremely contagious disease that causes death), DNA immunization (a new technique applicable to all types of diseases), and transgenic plants for immunization against hepatitis, pertussis, and polio. As of now, AIDS in Western countries has declined, while in Africa and Asia its spread has accelerated. Combination therapy for AIDS has had a profound impact on the level of the virus in the body; however, the treatment is still vague. The good news with regard to AIDS is that education is having an impact; this is exemplified by the situation in Thailand, where the government together with nongovernmental organizations and the military has begun a crash education campaign regarding prostitutes and the use of condoms. Progress is being made in the search for better vaccine candidates. AIDS-like epidemics involving new diseases are bound to emerge at some future point, though, given the long-term historical trend.
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PMID:New drugs, new vaccines, new diseases. An interview with Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases (NIAID). 1234 52

Economic studies of vaccines, including vaccine development and delivery issues, are increasingly needed to inform policy recommendations and programmatic decisions in the USA. This need arises from the increasing costs of vaccines, the complexity of the US healthcare system and the limited number of vaccine manufacturers in the market. We have developed a national research agenda in domestic and global vaccine economics by conducting key informant interviews with 42 experts and inviting ideas from an additional 128 experts. To assess priorities among the 129 ideas that were generated, we asked 15 experts representing a broad range of perspectives to rank the ideas and we analyzed their votes. The highest-ranking domestic research ideas included evaluating: the costs of vaccine shortages, the cost-effectiveness of potential human papillomavirus vaccination and adult and adolescent pertussis vaccination programs and the cost-effectiveness of universal vaccine purchase programs for adults as well as children. The highest-ranking globally-oriented ideas included developing a resource allocation model to support the best vaccination program decisions with limited funds and assessing the cost-effectiveness of HIV, rotavirus, meningococcal and malaria vaccines in developing countries. To optimize the usefulness of vaccine economics research, conceptual issues, such as how to set values for the prevention of illness and how to maximize social equity through investments in vaccines, must be addressed.
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PMID:Emerging issues in vaccine economics: perspectives from the USA. 1290 81

Oral polio vaccine (OPV) and diphtheria-tetanus-pertussis (DTP) vaccines are given simultaneously in routine immunisation programmes in developing countries. It is therefore difficult to determine the separate effects of these vaccines on survival. We used the shortage of DTP vaccine in Bissau to examine the impact of OPV on the case fatality at the paediatric ward in Bissau. For 719 children less than 5 years of age whose vaccination card had been seen at admission and who had not yet received measles vaccine, having received OPV only was associated with a case fatality of 6% compared with 15% for children having received combined DTP and OPV vaccinations, the case fatality ratio (CFR) being 0.29 (95% confidence interval (CI) 0.11-0.77). Even if children fleeing the hospital were assumed to have died shortly after leaving the hospital, the case fatality would still be lower for children having received OPV only (CFR = 0.41; (95% CI 0.20-0.81)). The tendency was similar for children hospitalised with pneumonia, diarrhoea, and presumptive malaria. Control for background factors had no impact on the estimate. In areas with high mortality, OPV administered alone may have non-specific beneficial effects or DTP may have a negative effect for children who had received both DTP and OPV.
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PMID:Oral polio vaccination and low case fatality at the paediatric ward in Bissau, Guinea-Bissau. 1570 66

Biodegradable microspheres may represent a potential tool for the delivery of combination vaccines. We demonstrate strong immunogenicity of five co-encapsulated antigens after a single subcutaneous inoculation in guinea pigs. Tetanus- and diphtheria-specific antibodies were not significantly affected by the presence of either antigen or by the presence of pertussis or Haemophilus influenzae type b (Hib) antigens. Microsphere formulations gave better protection against diphtheria toxin than did two injections of a licensed tetravalent vaccine. Finally, a synthetic malaria peptide antigen (PfCS) also encapsulated in PLGA microspheres increased diphtheria and tetanus-specific immunity and improved protection against diphtheria. These findings demonstrate the potential of microspheres as an alternative and promising strategy for combination vaccines with a further aptitude in reducing the number of inoculations required to gain functional immunity.
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PMID:Childhood and malaria vaccines combined in biodegradable microspheres produce immunity with synergistic interactions. 1545 93


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