THE 1986 REUIE.W OF THE

EXPANDED PROGRAMME ON IMMUNIZATION IN THE

UNITED ARAB EMIRATES

20 October - 10 November 1986

Report of the Joint Government of U.A.E./WHO/UNICEF Revie� Team

1. SUMMARY REPORT

1.1 Introduction

The purpose of the review was to assess the progress made in the Expanded Programme on Immunization and other closely related PHC activities, such as MCH and Health Education. This assessment aimed to highlight achievements of the programme under review. identify problems. make relevant recommendations and suggest appropriate steps to be taken in respect of the identified problems.

This joint Government of the United Arab Emirates/WHO/UNICEF EPI programme review was agreed with the view thj!t the findings would be utilized for achieving the goal of 95 percent immunization coverage of children under 1 year of age in the U.A.E. by the year 1990.

1.2 Methodology

A Review Team of S international members of WHO and UNICEF, and 7 members from the Ministry of Health of the U.A.E. carried:out this evaluation exercise from 20 October to 10 November 1986. The Review Team spent some time in reviewing the central/federal level of the programmes under review. Following this initial assessment, a random sample of 30 urban and 30 rural clusters was drawn. All urban and all rural areas were given equal chance to be selected in all the seuen Emirates and at such a proportion of distribution that was representative of the population of each area. These cluster surveys aimed in assessing the immunization coverage of children aged 12-23 months against the 6 EPI target diseases. Tetanus toxoid immunization coverage for pregnant women was not considered because in the U. A. E. approximately 9Stt of women deliver in hospitals and neonatal tetanus has been eliminated. These cluster surveys also included questions addressed to the mother of the children in relation to immunization, health services utilization, MCH care, health education and the use of ORS. In the context of the cluster surveys the Review Team examined 1421 children for their immunization status and interviewed their correspdnding mothers.

In addition.4 Medical Districts headquarters and 12 MCH centres and health clinics nearest to the clusters were visited in order to evaluate the immunization and other related services that these facilities provide. The cold chain of these outlets was also evaluated.

On completion of the field visits the Review Team returned to Abu Dhabi, compiled and analysed the data, discussed the main findings. identified the achievements and major problems. formulated recommendations and suggested steps to be taken.

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1.3 Main Achievements

On the basis of this review we believe that the U.A.E. have made advanced progress on a considerable number of EPI and other related activities. The following can be regarded as major achievements:

1. The high quality health care infrastructure that exists in all Emirates, in both urban and rural areas, is a sound ground for the implementation of PHC strategy.

2, The achieved immunization coverage showed that the programme is now reaching almost every child in the urban areas. The DPT first dose coverage being 90� whereas it'reaches 75% of the children in the rural areas. DPT and Polio third dose coverage reached 80% in urban and 55% in rural areas. What is remarkable however, is the progress made in the immunization coverage in the rural areas. Whilst this stood at 1' 1% in 1981 it is now at the level of 47%. The fully immunized children {including measles vaccine) was found to be 60% nationwide whi_ch shows an increase of approximately 18% to that of 1981.

3. The follow up system for defaulters which includes postal reminder cards, telephone calls and home visits, has resulted in a fairly low drop out rate particularly in the urban areas.

4. Vaccine procurement is control, which is now excellent.

satisfactory and vaccine _stock computerized, was found to be

5. It has become evident from the routine disease surveillance records that since 1981 there has been a significant disease incidence. reduction for all EPI target diseases except Diphtheria. The most remarkable disease incidence reduction is for Tetanus in the O - 1 age group which came down to 2 cases in 1985 compared to 16 cases for 1982.

6. It is remarkable mostly carried Departments of Districts. Both their activities teams.

to note that out through

Preventive are based in in the rural

the achievements in EPI were the MCH centres and the

Medicine at the Medical urban areas but they support areas through outreach/mobile

7. The ante-natal care through MCH centres and other heal th outlets in the country reached more than 90% of pregnant women who lived either in urban or rural areas. Breastfeeding is widely practiced in the U. A. E. and for at least 8 months for each child.

8. Health education has played an important role in the increase of immunization coverage and al though one cannot make an objective assessment of the impact of health education through this limited evaluation, it was clear

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from the field information that people were sensitized • through mass media and health personnel on health issues

such as immunization. The establishment of a health education unit at the Ministry of Health is already a major step forward in improving the inputs of health education in the course for health for all.

9. The high level of commitment to PHC by the Ministry of Health is evident by the Ministerial Decree No. 139/1986 which was especially issued for the adoption of PHC in the U.A.E.

10. The Review Team was pleased to see that most of the ' recommendations made in the 1981 programme review were favourably considered and implemen�ed to a large extent.

Although the aforementioned achievements highlight the successful aspects of the programme, there are still targets to be met and a number of problems to be solved in order to accomplish the goals by the year 1990. In this respect the Review Team identified main problems, formulated recommendations and steps to be taken as follows:

P R O B L E M S

I 11. Although the existing health I infrastructure is a sound I ground for implementing the I PHC strategy, it was found I during the review that some I of the existing MCH centres I were planned to either I be closed or reallocated I to PHC Directorate, I I 12, During the field visits it

was clear that not all health outlets, and in particular the primary contact clinics in the rural areas, were offering immunization, ante-natal or child care services.

3, During the field visits it was observed that the majority of health personnel were qualified for the tasks assigned to them, However there was lack of team work to a large extent, and the majority of them were expatr­iate with different educat­ional background.

MAIN PROBLEMS AND MAJOR RECOMMENDATIONS

R E C O M M E N D A T I O N S

-The Ministry of Health should ensure that these model MCH centres should continue to function, become training centres for immunization and other PHC activities and be integrated into the new PHC strategy.

In view that immunization coverage in rural areas is still well below of that in the urban areas, it is recommended.that all peripheral health outlets. including the primary contact clinics, should offer immunization and other related services,

The continuing education activities should be strengthened and extended to all categories of health personnel and in particular for those expatriates that deliver EPI and other related activities.

STEPS TO BE TAKEN

In order to achieve the set objective, dialogue should be developed among all those concerned to ensure the smooth integration of the services.

Establish the necessary minimum facilities for immunization including cold chain equipment and and set the frequency of immunization sessions in each centre according to the local needs.

The Ministry of Health in collaboration with WHO and UNICEF should first establish priorty areas and plan the future training activities.

PROBLEMS I RE COMME N D AT IO N S ) STEPS TO BE T AKE N l----------------------------------

14, The insufficient number of I· Encourage nationals to join Preventive Medicine I- Incorporate rele�ant I different categories of health services and give them appropriate training opportuni- I preventive medicine and I personnel among nationals and ties as well as other incentives for gradual replace- I PHC courses in ·the I in particular in the area of ment of expatriate staff, I Medical and Health Science I Preventive Medicine is a I curricula. I constraint on the future I I development of the health I services in the U. A.E .. I I I 5. It is evident that the drop­

out rates between OPT1-DPT3 and OPV1-0PV3 in r-ural areas is still high.

6. The Measles coverage is well below that of other EPI vaccines, It seems that health personnel are also resistant to providing Measles vaccination to each and every child.

Efforts should be made to reduce these drop out rates through well orientated health education and through strengthening of the defaulters follow up system in the rural areas.

Accelerate Measles vaccination activities through improved health education for the public and orientation training for the health personnel,

Offer more post-graduate training in Preventive

Medicine and PHC.

-Establish health education activities that are more orientated to the cultural conditions of the rural areas.

- Defaulters follow up system should be revised in rural areas, with probab­ly more frequent homo visits.

- Create special promotive activities on the value of Measles vaccination.

- Health personnel involved in immunization activit­ies should be orientated in Measles vaccination through special short training refresher courses.

I

V'I

I P R O B L E M S 1---------------1 7, The practiced list on contra­I dications to immunization I is long and elaborate. I I I I s. I I I I I I I I I I I

Although the Private Sector's share in immunization services is only approximately 10�, the contribution of this sector becomes more important in terms of quality in vaccinat­ion, as the immunization coverage rises.

9. VACCINE POTENCY IS AT RISK:

la, The cold chain and vaccine I handling is weak at all levels I I I I I I

Practical training and field supervision is absent,

lb, Cold chain monitoring and I evaluation is not carried out I I I I I I I I I

R E C O M M E N D A T I O N S

The Ministry of Health should try to adopt a new national policy on contra-indications that will comply with the current WHO recommendations.

The Ministry of Health should initiate activities that will aim at the proper supervision of the private sector's immunization activities.

a. To improve vaccine handling and cold chain it is recommended that the Ministry of Health recruit and establish a strong team to conduct extensive practical training of all staff concerned with immunization and provide continuing follow-up supervision.

b. Improve equipment used for vaccine storage and supervision is absent.

Carry out an extensive field evaluation of the cold chain.

STEPS TO BE TAKEN

Establish a group- of experts to revise the national policy on contra-indcations to immunization.

As a first step a random sample survey of the immunization practices in the private sector can ba dona by using the protocol made for this purpose by the review team.

a. Determine the requirement. b. Develop a plan. c, Recruit personnel d, Implement plan.

a. Determine the requirement. transport.

b. Procure equipment distribute and install,

c. Train personnel

a, Plan an evaluation of the cold chain.

b. Procure supplies. c. Implement the evaluation. d, Improve the cold chain

I P R O B L E M S 1---------------)10-The existing laboratories for I communicable disease I surveillance are inadequate I for accurate diagnosis and \ disease outbreak investigation. I I 11-The standard of quality of

service in MCH care is high but the acc@ss to this service in the rural areas is more or less limited .

12-It is clear that the Health Education Unit at the Ministry of Health requires further development. strengthening and support,

13-The .review team felt that the rural areas need more attention in person to person health education

R E C O M M E N D A T I O N S

The Ministry of Health should look into the establishement of a central Public Health Laboratory and the strengthening of the laboratories at the Preventive Medicine Departments in the Medical Districts.

Maintain and consolidate the high attendance to MCH services in urban areas and extend and improve them in the rural areas,

The Ministry of Health should allocate sufficient personnel and funds in order to ensure a more comprehensive and extended heal th education programme�

The outreach/mobile teams and rural health clinics should be designated for the person to person health education.

I I I I I I I

STEPS TO BE TAKEN

IExtend provision of MCH lservices to include peripheral )health clinics at the rural I areas. I I I IAn initial assessment/study of lthe needs and priorities in !Health Education should be made lby the Ministry of Health. I I I I - Provide adequate training and I orientation for these health I workers, I - Strengthen the health clinics I and outreach/mobile teams to I meet the needs. I 1------------

2. INTRODUCTION

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The Government of the United Arab Emirates represented by the Ministry of Health is strongly committed towards achieving health for all by the year 2000.

The Ministry of Health has adopted the strategy and policies of Primary Health Care as the tool for achieving health for all and in accordance with Ministerial Decree No. 139/ 1986 was issued for the adoption of PHC strategy.

A national plan of operation and plan of action for Primary Health Care ( 1986-1990) has been developed and the implementation of Primary Heal th Care Policy and programme started in June 1986.

Special•emphasis of the Primary Health Care programmes will be directed towards taking the priority health problems as specified in the PHC document published 1986. At this stage the Ministry of Health felt that a review or an evaluation of the present achievement of the EPI/MCH would provide basic data for further development.

On the request of the U. A. E. Government, a joint Government/WHO/UNICEF programme review of the Expanded Programme on Immunization (EPI) and other related PHC activities was agreed upon. The objectives of the programme review were:

1. To study and evaluate the EPI situation in the U. A.E. and recommend measures to facilitate the implementation ·of acceleration strategies in order to increase the immuniza�ion coverage of children and improve the standards of EPI activities to ensure high quality immunization. Such action would lead to the achievement of 9St. immunization coverage of all children under 1 year of age in the U. A. E. by the yeRr 1990.

2. To review the health care delivery system in the country in relation to EPI activities. identify obstacl�s and constraints, and recommed appropriate measures whereby the above stated obj ectiue could be attained.

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Accordingly WHO/EMRO assigned Dr. Michael Uoniatis as a coordinator of the review mission who arrived in Abu Dhabi on October 17, 19 86. Following 3 days of preparatory work with the national authorities the following terms of reference were assigned to the review team:

- The evaluation of the immunization coverage against the six EPI target diseases in children under one year of age.

- The study of the organization of EPI services within the context of the overall health care delivery system, and the implementation of PHC in the U. A. E. at all levels, including the -Ministry of Health (MOH), Dubai Medical Services, Minis try of Defence, Petroleum Companies, the Private Sector and others • •

- The review and assessment of EPI facilities including heal th facilities providing EPI services such as Health Centres, Hospitals and others: health manpower involved in EPI activities and the continuing training of their personnel.

- The review of Health Information System and in particular that related to EPI services focussing on morbidity and mortality patterns of the EPI target diseases.

- The study and assessment of the EPI logistics system and particularly with regards to the cold chain operation.

Reference was also made to the first EPI programme review*· which was conducted in March 1981. The implementation of the recommendations and the progress made since then were considered in the context of the present review.

* 11 A Report on the Expanded Programme of Immunization Programme Reuiew in the United Arab Emirates", March 1981 (EM/12/18). WHO, EMRO,

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3. METHODOLOGY

3. 1 Timing

The Programme Review was scheduled to start on 20 October 1986 and to be completed by 10 November 1986. The first day was devoted to the official inauguration, briefing on the programme actiui ties and protocols used. The central level programme review took place during the whole period of the review. On the second day a one day workshop for EPI Supervisors was conducted in Dubai. The objective of this workshop was to familiarize the national �ounterparts participating in the programme review with the content and methodology, and EPI evaluation techni"ques. The agenda of the workshop is shown in Annex 1. Following the completion of the workshop fiue local teams were formed in order to assist 'the international and national teams in conducting the cluster survey in the 8 different medical districts of the country. The list of members of the international and national teams appear in Annex 2. On the third day of the review the international team supported by the national counterparts moued in the evaluation of District headquarters, heal th centres and clinics, and to conduct the field survey which was completed in the space of twelve days.

All the information and data collected were compiled and analysed. Problems and constraints were identified and recommendations with steps to be taken were suggested.

The detailed time-schedule appears in Annex 3.

3.2 Programmes under review

Conforming with the terms of reference assigned to the review team the evaluation focussed on EPI, with particular attention to the cold chain. MCH services, Health Education· and Disease Surveillance were also reviewed.

3.3 Areas covered

The review was designated to be countrywide, covering all the seven Emirates, but with particular attention to differences between urban and remote (rural) areas.

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3.4 Workload • Two- 30 cluster surueys. one for urban and one for remote (rural) areas, were conducted. In addition the reuiew team uisited and eualuated 4 District Headquarters and 12 MCH centres and clinics nearest to the clusters.

A total of 421 children were included in the reuiew and checked for their immunization status. A corresponding number of mothers were interuiewed in relation to knowledge and practices pertaining to immunization and MCH seruices.

3. 5 Cluster Surueys

Due to distinct demogeographic and social differences and differ,ences in the auailabili ty of immunization seruices. the cluster suruey was designed to couer these strata and compare urban and remote (rural) areas.

For this purpose it was decided to carry out two 30 cluster surueys. one for urban and one for remote areas. All urban and all remote (rural) areas were considered at the random sampling of the clusters. The distribution of clusters was based on population interuals. Population data were collected from the Ministry of Planning. The population frame used was family based in order to exclude the large number of expatriate single male workers in U. A.E. The 1981 Population Census Report was used, but compared fauourably with the yet unpublished 1985 population census. lhen a random selection of squares in urban centres and villages in remote areas was carried out from the town maps and official lists of villages respectively. A map of the selected clusters is attached and the list of clusters is given in Annex 4.

3. 6 Protocols

The WHO PHC Review protocols were used for the Reuiew, but they were modified to suit the U. A. E. conditions. Bilingua� Arabic/English cluster suruey protocols were developed to facilitate the field work.

4. GENERAL INFORMATION

4.1 The country and the eeoele

The United Arab Emirates (UAE) federation was founded on the 2nd December 1971. It comprises seuen members, Abu Dhabi, Dubai, Sharjah, Ajman, Umm Al Quwain, Ras Al Khaimah and Fujairah. It occupies an area of 77,701 square Km, a size which is comparable to Jordan. It shares common borders with the Kingdom of Saudi Arabia. the Sultanate of Oman, and Qatar.

ARASIAN GULF

DISTRIBUTION OF CLUSTERS IN THE UNITED ARAB EMIRATES

0 M A N

Urban Clusters©

Rural Clusters©

GULF

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The Emirates can be divided into two geographical �egions: the rural farming area in the north and east and the.rural bedouin area in the south and west. The latter area coincides for the most part with the Emirate of Abu Dhabi, which comprises . 871' of the entire area of the Emirates.

The climate is subtropical being very warm in summer and moderate from November to February.

4.2 Communications and transpor� '

A good road network exists throughout the country and most remote areas can be reached by adeq_uate roads. Private transport is widely available among the population in both urban and rural areas. Telecommunications are widely available in all areas. Television and radio broadcasting are transmitted throughout the Emirates, and TU and radio receivers are available in almost every household in both urban and rural areas.

4. 3 Population

The total population of the U. A. E. reached 1. 306. 200 in 198S. while it was 1, 042, 000 in 1980.*

The male population of the age group 20 - 44 constituted 41� of the total population, a feature which reflects the size of immigrant labour force in the country (see population pyramid Graph 1)

Total population Number below 1 year

Number of 1-4 years

1, 306, 200 44, 410 or 3.4� of the total population 158, 0S0 or 12.l� of the total population

Number of women 15-4S years : 190, 7 05 or 14.6� of the total population.

It is estimated that 74� of the population liues in urban areas. The distribution of population by sex and Medical District is shown in Table 4.1.

* Source: Ministry of Planning

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GRAPH [ 1) Populallon Pyramid • (In T11011Nnd1)

IS♦ I

10-U □Mda

15-1' ■ Fmwa.

7:.7,

U..t

'°"" 5S-St

)0..54.

4s-4t

40-44

JS-Jt.

,0..)4

25-2'

20-24

15-H

10-14

s-, 1-4

0-1

1'0 140 120 100 IQ 40 20

- IS -

Table 4. 1

Population Distribution by Medical District and Sex (1985 Estimate)

I I IMedical District % of Total Male I Female I I

I I I Abu Dhabi 31. 7 1414,000 l304,300 (109,700

I I I •

I I Al Ain 11. 8 1154,400 (100,600 53,800

I I

I I I Dubai 25.9 (338,500 (223,100 (115,400

I I I

I I Sharjah 15.4 1200,500 (126,300 74,200

I I

Ajman 3. 7 48,700 28,300 20,400

I Umm Al Quwain I 1. 1 15,400 9,700 5, 700

I Ras Al Khaimah I 7. 2 93,200 56,800 36,400

I

Fujairah 3.2 41,500 26,000 15,500

�

I I I TOTAL 11,306,200 1875,100 1431, 100

I I I

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4. 4 yital Statistics and Health Indicators

Uital statistics and health indicators are shown in the table below.

Table 4.2: Vital Statistics and Health Indicators

Crude birth rate (per 1000 population) Crude death rate (per 1000 population) Rate of population increase Infant mortality rate (per 1000 live births) Mortality rate 1 - 4 years Materna� mortality Life expectancy at birth (in years)

Percentage of population served by:

* 1984

Safe water supply (per cent) Excreta disposal facilities (per Literary rate (per cent) Gross Domestic Product (in US$)

Total cent) Total

Total

�.

27.3 17.2 10. 1 12.1 N.A. N.A. 61. 5*

65.0*

80* 80* 76* 23, 194*

It is obvious that most of �he health indicators compared favourably with developed countries. This is due to a large extent to the immense socioeconomic development that the country has undergone over the last 10 years.

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Differences in crude birth rate. still births. neonatal and infant mortality rates among the 8 medical districts are shown in Tables 4 .J and 4. 4

TABLE 4.J TIIECRUOEDIRTU RATE.CRUDEOEATII RATE&NATUI\AL

rorOULATION INCREASE UY DISTRICT FOR TUE YEAR 1984

Total Toca( Total

� ct ropul. Births Deaths C.B.R. C.O.R. N.P.I.

ABUOHABI 402100 11.596 ltS 2.111

Al-AIN 149◄00 7,096 S71 4.71

DUBAI )27000 11,430 1,016 l.29

SHARJAH 194900 6,0ll i9l J.0l

AJMAN 46200 l,6SS 114 l.67

UMM AL-QUWAIN 1S000 5S6 l6 J.62

RASAL-K.HAIMAH 90200 ),◄84 176 J.78

fUJEIRAH 40100 2,14S 147 5.3)

TOTAL 1265100 0,99S l,I 17 ).38

• Note: High NPI in Fujcirah and Al Ain.

TABLE 4.4

COMPARISON OF STILL BIRTH RATE AND

INFANTMORTALITYRATEDY DISTRICT

FOR THE YEARS !981-1984.

0.20 2.H

O.JS 4.37.

0.29 l.tl

0.15 2.9S

o.n l.J4

0.23 J.47

0.19 J.67

0.37 4.96

0.24 l.2l

-�

1981 1982 1983 1984

Disuia S.B.R. I.M.R S.B.R I.M.R S.B.R I.M.R

ABUDHABI 6.20 11:l◄ 6.40 IS.S7 8.20 ll.JS

'AL-AIN 11.00 18.86 9.90 19.10 11.00 18.46

-DUBAI 2.SO I.II 12.20 20.34 ll.80 21.20

SHARJAH 1.6 l.60 9.20 22.77 9.30 4.79

AJMAN 6.00 tl.2S 9.70 17.0S 15.20 2S.76

U.A.QUWAIN 12.20 7.90 2.62 6.60 6.59

R.A.KHAIMAH 6.20 6.IS 7.90 l.11 7.00 9 .58

FUJEIR.AH 12.30 U.69 6.80 4.09 11.10 6.21

TOTAL: S.60 10.54 9.20 ll.98 10.60 14.65

Source: Annual Report of the Department of Preventive Medicine, Ministry or Health, 1984.

S.B.R . 1.M.R

8,97 I�.&,

11;70 16.49

ll.16 19.16

8.SS 10.44.

II.JS 22.96

J.58 7.t,

8.26 9.47

8.32 6.Sl

9.86 tS.06

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5. ADMINISTRATION AND ORGANIZATION

The health care delivery system in the U. A. E. has undergone further development since the previous EPI programme review. This feature was part of the ovreall socio-economic transformation which occured in the U.A.E. during this period of time.

The population of the U. A. E. has increased by about 20% since 1980. (Ministry of Planning - population projection) .

The expansion of Health and Medical Services could be clearly exemplified by the increase in the total number of hospital beds from 2907 in 1981 to 3785 in 1986, with an increase of about 30% (table 5.1) .

* (includes

Table (5. 1) *Distribution of Hospital Beds in the

U. A. E. by Medical District for the Years 198 1 and 1986

ill!.

Abu Dhabi Al-Ain Dubai Sharjah Aj_man U. A. Q R. A. K. Fujairah

To ta 1 ( U . A . E . )

Number 1981.

872 494 795 336 85 28 1725 125

2907

of Hoseital 1986

1692 75 1 227 449 139 120 331 136

3785

the.Ministry of Health facilities only)

Beds

Figure I, illustrates the organizational chart and the line of responsibilities which is currently adopted by the Ministry of Health. Presently EPI comes under the jurisdiction of the Department of Preventive Medicine' both at the federal and district level. At the district level EPI is delivered through hospitals, MCH centres and outreach teams. The Director of Preventive Medicine in each Medical District is responsible for programme implementation and supervision.

Dop. ",_ ..... __.

a-nl

PTolr--.1 nlau1 fll U-b T�

e-r-

CVUZHr ma.uaunoiw. auu o, na: �Y o. Kr.U.TH

lfflflJTU OP HLU.'TH

,mmnn1Ull1AU

\.!HOD sta.ff.l,_Y 01 MV.t.nt

0.,.11.-- °"".,,.__, a...11.tll .... � . ..,,..

n..- ...... ....... .... ,,,,...

T,..,,..o\ .U.W...lloa MIiia-al

Wlrbl,op M.aalt.qpca.

-- �., .........

1GOH CIOMMITnl OP HEAL'ffl

.,.,..,,,_ .........

c.....1-caw.Illa.

M.C.H.

�· Doadl ff ...

EPI ........

1>11'- "·c.,,,,,,, M.-..

Ollpllll.a �

Mollll c:wr.

T ........ TnWa

Jdal., ,,.,.,

- 20 -

Preuentiue Medicine Seruices haue also deueloped during this period· of time although most of the financial support was directed towards therapeutic seruices.

According to the 1984 annual .report of the department of Preuentiue Medicine. the seruices of this department couer the following desciplines:-

- Maternal and Child Health Seruices

The Expanded Programme of Immunization

- Control of Communicable diseases

- Health Education

- School Health

- Enuironmental Health

- and Occupational Health

Some of the disciplines under preuentiue medicine seruices haue significantly deueloped since the preuious programme reuiew including disease surueillance and control programme especially with regard to periodical reporting of communicable diseases in general and the EPI target diseases in particular.

6. BUDGET ANO FINANCE

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The Ministry of Health draws its budget from the federal government of the U. A.E. It constitutes 1. 5% of the national income and S. 7� of the federal budget. Until the year 1984 ·the per capita Ministry of Health budget was 900 U.A.E. dirhams (2SO US Dollars)

Although the Ministry has a comparatively high budget compared to many other countries. the indiscriminate allocation of such· a budget in addition to the channelling of a high percentage of the budget towards the development of the curative services infra-structure. such as hospitals and high • technology equipment has retarded to a large extent the vertical programmes, especially those of preventive medicine. including EPI and MCH services. This is due to the absence of specific budget allocation to such programmes • •

6. HEALTH ESTABLISHMENTS

6. 1 General

The Ministry of Health establishments have significantly increased over the past S years. They have become more accessible to all urban population and a large proportion of the rural population.

The physical facilities of the Ministry of Heal th and other sectors until the year 1986 are illustrated in Table 6.1.

They are evenly distributed throughout the eight medical districts but they are mainly concentrated in urban centres.

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Table 6.1 •

HEALTH FACILITIES IN THE U.A. E. DISTRIBUTED BY MEDICAL DISTRICT. URBAN Us AREAS ANO TYPE FOR THE YEAR 1986

I I I HOSPITALS I I I DISTRICT M.O. H. IPRIUATE I OTHERS IHEALTH CENTRES* I I I I

I IABU DHABI u 4 1 3 1�

I R 4 11

I I AL AIN u 1 1 1 6

I R 1 11

I IDUBAI u 2 1 4 6

I R

I I I ISHARJAH u I 2 2 I 3 I R I 3 I 9

I I IAJMAN u 2 1 I I R 1 2 I

I I I JU.A.Q. u 1 I 2 2 I I R I 2 I I I -l I I IR.A.K. u 2 I 3 ' I R 1 I 13 I

I IFUJ'IARAH u 1 2

I R 1 3

I JTOTAL u lS 5 10 39. I R 11 0 0 Sl

I I !TOTAL UAE. 26 5 10 1 90

* Does not include Priuate Sector clinics

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6.2 Federal District Preventive Medicine Departments: Field Observations

The three medical districts' Preventive Medicine Depart,ments reviewed operated in relatively different ways and had different levels of responsibility.

The common operational features �ere technical supervision, vaccine supply to health centres, clinics, and hospitals, as well as a laison/coordinating role with the local government health departments. The district level is responsible for monitoring and reporting of field level" activities. performance. and data on disease surveillance.

Most district Preventive Medicine Oep�rtments operate MCH Centres within their district headquarters and provide outreach services to more remote areas. Some formal and informal in-service training takes place at this level,

6.3 Municipal Preventive Health Services: Field Observations

In a number of Emirates the municipalities are independently developing the capacity for the provision of preventive health services including immunization services. The current Dubai Heal th· and Medical Services programme is particularly strong and well conceived with a clear plan to provide high access primary/community health care.

Dubai Heal th and Medical Services operated an extensive well managed and resourced network of hospitals and clinics throughout Dubai Emirate. Independently of the Federal Ministry of Health it has planned its programme, constructed facilities, recruited staff. and provided technical, managerial, and logistic support for its preventive medicine ser�ices.

In the mid 1960' s Dubai Health and Medical Services (OHS}, provided hospital based immunization services, and in 1977 began to implement a mobile/outreach approach to increase coverage. Following the adoption of a Primary Heal th Care strategy in 1986 the number of immunization delivery outlets have been increased through the utilization of the network of existing clinics.

OHMS plans envisage the provision of community hospitals. each serving about 30,000 population, supporting a satellite network serving 2,000 to 3.ooo people. Immunization and MCH services would be provided by General Practioners. No plans exist for the involvement of local community and voluntary organizations in the provision of health care.

- 24 -

6. 4 Health Centre Management: Field Obseruations

6.4. 1

6.4.2

MCH Centres

MCH centres are operated by the MOH Preuentiue Medicine Department. and are usually managed and superuised by the Director of Preuentiue Medicine Departments of the medical district in which it is located.

These centres prouide a wide range of quality seruices including antenatal care ., child heal th clinics. child deuelopment clinics. immunization ., health education. and nutrition as well as curatiue treatment and referral seruices. All MCH Centres are' in urban areas. With one exception there is no community participation in the prouision of these seruices.

While seruing an auerage of some 97 children each day, these well planned centres prouide a pleasant atmosphere public and the centres' health staff.

mothers and laid for both

and out the

These well equipped centres appear to neglect routine maintenance and repair of the equipment in daily use.

Staffing leuels appeared to be adequate in•most centres (75%) . It has been noted ., howeuer., that trained staff are frequently transfered to other medical seruices without consultation. For the most part uacancies are 'filled promptly.

Job descriptions are normally auailable and staff appeared to clearly understand their duties and responsiblities. Regular and frequent staff meetings are rare·.

Clinics/Health Centres

Clinics are operated by the MOH Curatiue Medicine Department ., and are out-patient clinics of hospitals in major towns ., · or day centres in the relatiuely smaller uillages and towns.

Superuision of clinic operations by national or district officers is limited and infrequent. No schedule of superuisory uisits and no superuisory check list was auailable in any clinic uisited.

These clinics were staffed by one or more medical officers., one or more nurses. pharmacists, para-medical and administratiue personnel, as well as driuers,

- 25 -

messengers. cleaners and watchmen� While staffing leuels seemed high at an auerage 11 staff per clinic some 8% of posts were reported to be unfilled.

Operating as a first contact health facility these clinics prouide a limited range of curatiue seruices and refer all cases which they cannot treat or inuestigate locally to the major referral hospitals. There is no local community participation in the prouision of health seruices.

Seruing persons. euening daily.

a population ranging from 200 to 10. 000 these clinics generally operate mt:>rning and

sessions and see an auerage of ·19 patients

All .these clinics uisited appeared well laid out. well prouided with equipment and furniture. Pharmaceuticals and other supplies · were well stocked. Routine maintenance appeared neglected in 18% of the clinics uisited.

With one exception all clinics had one or more ambulances and four wheel driue uehicles.

- · -··--- - ---------P R O B L E M S

--· · - • - ·-------------

1 . Although the existing health i nfrastructure is a sound ground for implementing the PHC strategy, it was found during tha review that soma of the existing MCH centres were planned to either be closed or reallocated to the PHC Directorate.

2. During the field visits it was clear that not all health outlets, and in particular the primary contact clinics in the rural areas, were offering immunization, ante-natal or child care s�rvices.

SUBJECT: HEALTH ESTABL ISHMENTS

R E C O M M E N D A T I O N S

Tha Ministry of Health should ensure that these model MCH centres should continue to function, become training centres for immunization and other PHC activities and be integrated into the new PHC strategy.

In view that immunization coverage in rural areas it still well balow of that in the urban areas, it is recommended that all peripheral health outlets, including the primary contact clinics, should offer invnunization and other related services.

STEPS TO BE TAKEN

In order to achieve tha set objectives, dialogue should be developed among all those concerned to ensure the smooth integration of the services.

Esta_blish the necessary minimum facilities for immunization including cold chain equipment and and set the frequency of immunization sessions in each centre according to the local needs .

l'\l 0-

7 . HEALTH MANPOWER

7 . 1 General

- 0::. I -

T he total number of techni cal doctors and nurses and their distric t is shown in table 3.

personnel represented by distribution by medical

By the year 1984 there were 792 specialists. 556 medical :officers and 3958 nurses. They constitute 0. 6 specialists. 0. 4 medical officers and 3. 1 nurses per thousand population of the U. A. E.

The above figures include only the doctors and nurses working under the Ministry of Health. The ratios would increase (about double) if other services such as Dubai Health and Medical Services. oil companies and Ministry of Def�nce services were included.

TADLE NO J RATIO OF SPECIALISTS� MEDICAL OFFICERS AND

NURSES PER t00O roruLAnON D ISTRIDtn'Ep nY DISTRICT FOR THE YEAR 198.

�

Total McdialOCficc:n spccialtsu Nunes , pop_ulacion Tot1l % Toc:ai Taul % %

Abu Dh:abi ◄02100 198 0.5 . 2S6.. 0.6 1460 3.6

AI Ain 149400 t i ) 0.8 129 0.9 79S S.J

Dubai 327000 68 0.2 77

Sh:zrj:ah 194900 69 0.'4 IJG

Ajm:an 46200 20 0.4 l l

U.A.Q. 15000 19 1 .3 26

R.A.K. 90200 39 0.4 101

fujeinh 40300 JO 0. 7 34

Total 126S100 S56 0.4 792

N .B. To include all Specialists. Medial Officers and Nurses in M.0. H.

• Onr.s noc include O.M.S.

7. 2 Field- observations

0.2 301

0.7 61S

o) 1 36

1 .7 ,a

I.I 404

0.8 1 49

0.6 3951

During the f'ield visits it was observed that the major.i-ty of the heal th personnel were 11Jell qualified for the tasks as signed to them. However. there was a lack of team work particularly ln rural located hospitals and lack of orientat�on towards PHC. The maj ority of them were expatriates with different cultural and eduactional background. Despite these problems and constraints they maintain a high quality standard for the services they provide.

The problems identified by health personnel at MCH centres and clinics could be summarized as follows : 1 . Limited health education activities. 2. Lack of sufficient staff 3 , Lack of Arabic speaking staff in remote (rural) centres. 4. Lack of laboratory facilities. S. Insufficient transport in remote areas. 6 . Lack of working refridgera tors . thermometers, weighing

scales and height scales .

0.9

J.2

2.9

6.S

4.5

3.7

3.1

P R O B L E M S

l . During the field visits it was observed that the maj ority of health personnel were qualified for the tasks ass igned to them, However there was lack of team work to a large extent. and the maj ority of them were expatt­iate with different educat­ional back ground,

2, The insufficient number of different categories of health personne l among nationals and in particular in the area of Preventive Medicine is a constraint in the future development of' the health services in the U.A , E . •

SUBJECT : HEALlll MANPOWER

I R E C O M M E N D A T I O N S STEPS TO BE TAKEN ,------------------------ -------------

The continuing education activities should be strengthened and extended to all categories of health personnel and in particular for those expatriates that deliver EPI and other related activities.

Encourage nationals to J oin Preventive Medicine services and give them appropriate training opportuni­tie1 as wall as other incentives for gradual replace­ment of expatriate staff ,

The Ministry of Health in collaboration with WHO and UNICEF should first establish priorty areas and plan the future training activities.

I- Incorporate relevant I preventive medicine and I PHC courses in the I Medical and Health �cience I curricula. I 1-, I I I I

Offer more post-graduate training in Preventive Medicine and PHC.

---------------- ---------------------------1---------------

N O>

- 29 -

8. EXPANDED PROGRAMME ON IMMUNIZATION

8.1 Introduction

The main objective of the immunization programme. which was established 10 years ago. is to protect all children in U . A.E. ·, as early in life as possible. against the six EPI target diseases and any- other diseases as seen necessary or relevant to the local situation in order to reduce morbidity and mortality from such diseases.

Immunization services are mainly provided by the Ministry of Health through the Department of Preventive ' Medicine in collaboration with other departments within the ministry as well as with other institutions and sectors involved in the provision of health care in the country .

• Inmmunization services are integrated in the overall national heal th programme in general and as an important component of PHC in particular.

There is no specific budget allocation for the EPI activities but financial and other resources are extracted from the general budget of the Ministry of Health.

8.2 Imelementation and Develoement of the Programme_

The implementation of the specific immunization strategies is carried out through a time-table designed in such a way that it should fulfill the operational targets as adjusted for the different geographical areas of the U. A.E.

The major goal is to immunize 95% of the children under one year of age against the 6 EPI target diseases.

8.3 Immunization Schedule

The immunization factors such a� effectiveness, acceptability.

schedule currently adopted is based on epidemiological situation , immunological operational feasibility and social

Consideration is given to periodic reviews and timely modification of · the adopted schedule. A recent example of this is the change of BCG vacccination to be given at birth from June 1986 instead of at 12 months. It is also considered that an effective schedule should be completed as early in life as possible.

I I I I I I

I I I I I I I

- 30 -

The currently adopted immunization schedule is shown below.

Table 8. 1 : Immunization Schedule currently adopted. in the U . A . E . C 19 8 6 )_

Age of Vaccine Child

I At Birth I BCG (since June 1986) 2 months I DPTl and OPUl 4- months I DPT2 and OPU2 6 months I DPT3 and OPU3 9 months I Measles

I l S months I Measles and Mumps (MM) At school entry I BCG for Tuberculin negatives

I OPU and OT Boosters I Measles and Mumps (MM)

10-12 years I Rubella (for girls only) I

I I I I

I I I I I I

8 . 4 Acceleration Strategies.

The most significant development which would affect immunization coverage in particular and the quality of he.alth services in general , was the adoption of PHC in the strategies of the Ministry of Health for attaining Health for All by the year 2000.

By the end of the first five year plan ( 1986 - 1990) there will be 135 PHC outlets distributed throughout the U. A . E . making the services more accessible and hence have a favourable impact on the immunization coverage.

Certain areas were specifically identified acceleration strategies and they include :

in the

- Intensification of Health Education activities and mobile services for remote areas.

- Closer and more organized cooperation with the private sector. A plan is already on the way for standardization of the immunization schedule used by all health institutions in the country including the private sector. The plan also covers procurement of vaccines, supervision of the cold chain and the improvement of information system and feed-back mechanisms.

8 . 5

- 3 1 -

- The development of a monitoring system whereby the mobility of mothers and newborns within the U. A. E. and neighbouring countries could be supervised with regard to immunization status of the children concerned. ·

Policy on Contraindications

The current policy on contraindications comprises screening by a physician of each child before any immunization is performed. Any disease or illness even mild fever, common cold and loose motions are regarded as contraindications to immunization.

8. 6 EPI Outlets

8 . 7

8 . 8

BCG vaccination is offered by all hospitals in the • country. All EPI vaccines are offered at the Preventive Medicine departments and MCH centres at the urban areas. The actual number of the District Preventive Medicine departments are only 8 and the MCH centres 14 of which 7 are in Dubai.

Training

Virtually there has not been any formal training on EPI in the U. A . E. However. in the last year a 4 hour training course for EPI outreach teams was held in Al Ain.

Immunization performed and coverage

Information on immunization coverage by age. antigen dose and medical district is readily available and contained in the 1984 and 1985 Annual Report of the Department of Preventive Medicine. Ministry of Health. The coverage estimation is based on the registered births versus tjle immunizations performed by the various Government outlet:s. In this respect the presented figures are an underestimate because they do not include immunizations performed by the private �ector, which is estimated to stand between 10 and 15 percent of the total. plus the fact that 10 per cent of registered births belong to people that live by the border of neighbouring countries (e. g. Sultanate of Oman) but who come and deliver their children in the nearby towns of the U. A. E. and then return to their own country.

The 1984 published immunization coverage by type of vaccine. dose. age and district is shown in table 8. 2. The per cent coverage for the year 1981 to 1984 by type of vaccine and dose is shown in table 8.3. " The trend shows an increase in the coverage for all doses and all antigens.

� �

EAR

1 98 1

1982

1 98}

1 984

- 32 -TAUi.i-: 8 . 2.

IMMUNIZATION C:O\'El\ AGI� DrSTI\ I IIUTt-:n ln" TVl'E O F VACCIN I,:.

nost-:. AGE-:. t, DISTLUC"r

fOl\ TI i t-: Yf-:Al\ H >B-l.

�

C. o.r.r. rouo .,. ti &&.I ::> w

C) 0 ..I

u < � < ci :re,.

0 In Znd Jrd 6 In ·2nd Jrd 8 � ABUOHA!U 0-1 ,0.7 . 7U 67.4 . ,0.7 74.1 '7.1 . JU 1 .J"

M 1.f u 4.4 47.t 7.7 u '5.4 41:, 2U 0.0

2•4 u 5.1 u J7.I 6.1 S.I u J7.l 7.0 IS.4

Al-AIN 0-1 77.J 61.1 47.1 . 77.J 61.J 47.1 . z1., 14. 1

1-2 ,., 10.I 12.1 J&.1 ,., IU 12.1 JU 16.7 JU

2-4 1 1.7 I I.I 10.7 4U I U 11.1 10.7 4t.J ILi 27.4

DUBAI 0-1 71.J 66..7 Sl.7 . IJ.6 7).9 ,s.1 . S.J 2U

1-2 s., 7.S u ' JI.J S.I 6.0 u 40.J J6.4 19.4

2-4 J.1 J.7 J.J IU 6.1 7.Z u 27.2 J.! I I.I

SHARJAH 0-1 77.t "-' SU . 71.6 ,u 59.1 . ◄U 4.1

1-.2 S.4 S.4 S.7 JJ.J S.7 LO s.z JJ.J 11 .6 J6.0

2-4 10.4 J.I J.6 ,., LZ u 4.4 JI., 7.7 u

AJMAN 0-1 90.6 7U ,u . ,0.6 76.6 ,u . 41.J 0.1

1-2 10.I 1.7 1 1.Z 44.2 IIU L7 1 1.Z 44.Z n.o 44.4

2•4 JO.I 1 7.9 1 7.S 12.7 JO.I 17.9 17.S U.7 7.4 S.4

U.A.QUWAIN 0-1 IOU ,s.1 II.I . IOU ,s. 1 IJ.J . 64.Z 16.9

1-2 7.4 12.2 10.1 SU 7.4 12.2 10. 1 61.7 11.0 50.4

2-4 1 0.1 u 1., 4&.I ,., , .. 6.1 46..I 6.7 JU

It.A.IC. 0-1 64. 1 SI . I 43.7 • · 65.0 51.J u.s . JZ.S ILi

1-.2 I.I 7.J 7.4 27.J I.I 7.0 7.S 27.J IU 17.4

2-4 I.I - 6.J 6.1 u.z 10.1 Lt u lJ.7 ,.s 2.7

FUJEIRAH 0-1 65.7 40.0 JO.J . 6U 40.0 JO.O . 21.5 0.1

1•2 U.9 ,., 10.Z 2',7 u., ,., 10.2 2',7 22.S . 11.S

2•4 t.4 4.0 J.7 25.1 t.4 4.0 J.7 25.1 IJ.I IU

TOTAL 0-1 I0.4 '6.0 57.1 . 11., 61.2 51.t . 29.7 10.,

1-2 7.6 7.J I.Z JU 7.6 "'' ,., JU 2J.7 Jl.4

2-4 I.J u '-' 11.t ,.a ,., '-' JS.t 7.4 )):4

TADLE 8 . 3 PER CENT COVERAGE FOR THE YEARS 1981 TO 1984

D YTYPE OF VACClNE & DOSE

TOTAL DPT rouo MEAS-

NO. OF BIRTI-1S tST 2ND JR.D 1ST 2ND JR.D LES

. .17,29) 15 5J •IS 1S SJ 45 4 .!

42,549 67 53 4.l 10 . 56 46 4 1

44,CJ I I 71 57 47 7l 58 so SI

4 )995 SIJ.O 7}.J 65.J. 89.S 75. 1 G6. 5 5) .4

• Oenominuor Used wu Toul Births

For Yeir 1 984.

BCG

1 $

42

)7

4 2 .}

8 . 9

- 3 3 -

Monitoring and Evaluation

it was clear that the Preventive Medicine Departmen t at the central level continuously monitors and evaluates EPI activities . A comprehensive report whic h covers all activities including immunization is produced annually . The Dire ctor of Preuentive . Medicine , Ministry of Heal th holds regular monthly meeti ngs with all the 8 Medical Di s trict Directors of Preventive Medicine in which problems with regard s to the ac tivities are d i s cu s s ed and s olutions are s ought .

8 . 10 Fiel d Obs ervations

Immu nization services were available i n . all of the MCH c entres , many of which o ffered both morning and evening vaccination s e s s ions . , .

About a third of public clinics ( health centre s ) offered immu nization services at one or more s e s s ions daily . In remote areas many of the se clinics were reported to b e under-utilized by the lo cal population who preferred to attend the hos pital outpatient clinic s .

Mos t other clini cs/health centres offered curative s ervices only .

Some 86% of all health workers have a clear u nders tanding of the national immunization s ch edule i ncluding the target age group . Thi s includes the s taff of centres which are not currently providing immunization s ervi ces .

Multiple contraindications are practiced at virtually all centres . including egg protein s ensi tivi ty s creening for measles vac cine eligibles . Other contra-indi cations practiced are : colds , fever, infections . cough , rhi ni ti s . loose motion s /diarrhoea . allerg y , and - dermatitis . Several centres es timated that 5% of eligibles are refuse.Ji vaccination at the time of a ttendance . This practice has been obs erved during the review .

I t was obs erved that during vac cination s e s s ions little time was given to informing the parent about side e ffects , reactions , the benefits and need to return for s u c c e eding dos e s .

While the centre s reviewed had no specific operational or coverage targe ts , other than a nominal 9 5% to 1 00%, no spec ifi c strategy related to the local community was implemented . Most centres provide immunization s ervi c e s to a lo cal catchement area as well as providing s ervices to individuals comming from remo te regions, other towns or cities . and in some cas e s neighbouri ng countries .

- 3 4 -

In a few remote (rural) areas, where out-reach/mobile teams operate or where home visits were carried out, a clear

' strategy for achieving coverage targets has been implemented.

In one remote area a pilot scheme involving the local branch of the Women ' s Association and UNICEF along with the MOH Preventive Medicine �epartment developed a strategy based on community participation and motivation .

Registrations of vaccinations performed are maintained in medical case record files, permanent registers, and in some centres on tally sheets. Monthly reports are sent to the Medical District Preventive Medicine Department for tabulation and analysis.

An intensive defaulter tracing system has been implemented in all· centres offering immunization services. Postal remin�er cards, telephone calls, and home visits are carried out to reduce the drop out rate.

8. 1 1 Cluster Survey Results

8 . 1 1 . 1

The data obtained from the two 3 0 cluster surveys was compiled and analysed. Each survey represented the urban and rural areas separately and included children aged 12 - 23 months.

The date given on the child ' s immunization card or the mother ' s testimony were accepted as evidence of vaccination. For BCG a date on the vaccination card was considered as evidence of immunization subject to confirmation of a posi tiv·e scar. Since there has been a very recent change on the immunization schedule for BCG (from 12 months to as soon as after birth) children were regarded as fully immunized if they completed 3 doses of DPT and Polio vaccine, and one dose of Measles before completing 12 months of age. The 3 doses of DPT and Polio vaccine were accepted as valid if only the spacing between them was more than 4 weeks and less than ·' 6 months apart.

Immunization Coverage .

The percentage · of immunization coverage as shown in Table 8. 4 indicates a high vaccination card retention rate which reaches 80% in the urban areas. The first dose of DPT and Oral Polio vaccine indicates that the current immunization programme reaches the majority of children in the U. A. E. particularly in the urban areas. The Measles immunization coverage appears less satisfactory reaching 65% in urban areas and 47% in rural areas. The fully immunized coverage stands at about 60% and this indicates that the programme has not been active enough to implement effectively Measles immunization for the maj ority of children . This is more true for urban areas where the drop out rate from OPV3 to

I !NUMBER

AREA I OF I CHILDREN ) EXAMINED

URBAN 210

RURAL 2 1 1

U , A . E . 421 (weighted

average)

Table 8. 4

IMMUNIZATION COVERAGE OF CHILDREN AGE 1 2 - 23 MONTHS CLUSTER SAMPLE SURVEY RESULTS (OCT 1986)

I I VACCINA- DPT % OPU % ITION CARD I AVAILABLE I % 1 I 2 I 3 1 2 I 3

I I I 80 90 86 I 81 89 85 80 I I

I 6 1 75 6 4 56 1 - 7 1 · 6 1 s�

I

75 86 80 75 84 79 74

I ! Measles ) VACCINE I % I

6 5

47

60

• BCG was considered separately because of the recent change in BCG immunization schedule.

I I !Fully I l lmmun- I l ized I I I Y ES

I I. 63 68 I

47 3 5

S9 59

I BCG*

%

I SC A R➔

52

26

45

w VI

Vaccines Area

URBAN

RURAL

U.A , E. (weighted

avera g e ) .

Table 8 , 5

DROP OUT RATES FOR DPT 1-DPT3, OPV1-OPV3, and OPV3 - ·MEASLES VACCINE CLUSTER SURVEY RESULTS

DPT l - DPT3 %

11

3 4

17

(OCT 1986 )

OPV l - OPV3 %

11

29

16

OPV3 - MEASLES %

2 3

17

21

w O'

Sector

Area

URBAN

RURAL

U.A . E . (weighted

average)

Table 8 , 6

VACCINATIONS PERFORMED BY SECTOR AND FACIL�TY CLUSTER SURVEY RESULTS

(OCT 1986)

GOVERNEMENT FAC ILITIES PRIVATE

HOSPITAL ! HEALTH CENTRE OUTREACH % I % % %

28 6 1 0 11

I 30 52 15 I 3

I

29 58 4 I 9 I

I TOTAL I

I % I

100

100

100

- 3 8 -

Measles uaccine is higher than in rural areas (see Table 8. S) . The BCG uac cination appears to stand on the high side despite the recent change in policy. although the BCG scar failure rate is approximately 29%. This indicates that such a high BCG scar failure might be due to faulty technique.

8.11.2 Drop-out Rates

The drop-out rates for the uarious antigens and doses are shown in Table 8 . S. The results show a low drop-out rate between DPTl and DPT3. and• OPU1-0PU3. OPU3-Measles drop-out rate is. howeuer. high and obuiously higher in the urban than in the rural areas. The ouerall picture in the rural areas is less fauourable and this might indicate differences in accessibility to health care facilities and cultural rejection of uaccination.

8. 11.3 Vaccinations Performed by Sector and Facility

In Table 8.6 it is shown that the priuate sector ' s share in immunization actiuities is 11% in urban and only 3% in rural areas. Although. this is not a big share . as immunization couerage approaches the 95% leuel this share becomes more significant in terms of the absolute numbers immunized by this sector.

On the Gouernment facilities utilization. in relation to immunization. it is clear that most of the work is done at the Health Centres (mostly MCH centres) in both urban and rural areas. whereas in rural areas 15% of the immunizations are deliuered by outreach teams.

8. 11. 4 Reasons for lack or incomplete Immunization

Following the analysis of the reasons for immunization failure (see Table 8. 7) it became apparent that unawa�eness of the need for immunization was the commonest reason encountered in both urban and rural areas (8. 6% and 15. 7% respectiuely). It is clear from the same table that the mother being too busy. the illness of the child and the distance of the immunization place were the main other reasons for failure in rural areas. The illness of the child and the mother being too busy also appeared to be important reasons for failure in urban areas.

Table 8 . 7 : Reasons for Lack or Incomplete Immunization

Reasons Given 'I URBAN 'I RURAL

. Lack of 1 , Unaware of need for immunization 8 , 6 15. 7

Information 2 . Unaware o t need to return for 3 . 3 4 . 3 for 2nd or 3rd dose

3 . Place and/or time of immunization 1 , 9 5 . 2

Unknown 4 , Fear of tide reaction 1 . 9 5 .7 5 . Wrong ideas about 2 , 4 2 : 4

contraindications 15 . Others 0 , 5 1. 9

Lack of 1 . Postponed till another time 1 . 9 3 . 3 . Motivation

2 , . No faith in Immunization 1. 9 2 . 9 3 . Rumours 0 . 5 1. 9 4 . Other 0 , 5 1 . 0

Obstacles 1 . Place of Immunization too 1 . 9 7 . 1 far to go

2 . Time of ill'llll.lnization - -inconvenient

3 . Vaccinator absent 1 . 0 -4 . Vaccine not available 1. 4 po . s s. Mother too busy 4 . 3 10 , 0 6 . Family problem, including 0 , 5 1. 4

il lness of mother 7 , Child ill-not brought 6 . 7 10 . 0 8 , Child il l, brought but not 4 , 3 2 . 9

given 9 , Long wai ti ri� time - -10, Father refused 0 , 5 2 . 9 11, 0ther 3 . 8 3 , 8

I

P R O B L E M S

1 . It i s evident that the drop­out rates between DPT1-DPT3 and OPV1--0PV3 in rural areas i s sti 1 1 hi gh.

2 . The Measles coverage is we)l behind from that of other EPI vaccines, It seems that health personnel are also resistant to provide Measles vaccination t o each and every child .

76T

SUBJECT : EPI

R E C O M M E N D A T I O N S

Efforts should be made to reduce these drop out rates through well orientated health education and through strengthening of the d efaulters follow up system in the rural areas .

Accelerate Measles vaccination activities through improved health education for the public and orientation training for the health personnel,

STEPS TO BE TAKEN

- Establish health ed ucati on activities that are more orientated to the cultural conditions of the rural areas ,

- Defaulters follow up system should be revi sed in rural areas, with proba� ly more frequent home visits,

- Create special promoti ve activities on the val ue of Measles vaccination.

- Health personnel involved in immunization acti vi t­ies should be orientated Jn Measles vaccinati on through special short training.

ont' d/2,

P R O B L E M S I

SUBJECT: EPI

R E C O M M E N D A T I O N S STEPS TO BE TAKEN l--------------------------- ---------------

D76T

3. The practiced list on contra- I dlcatlons to immunization I l s long and elaborate. t

4. The BCG scar failure ls hi gh and merits improvement

S , Although tha Private Sector' s share in immunization services ls only approximately 10�. the contribution of this sector becomes more important in tenns of quality in vaccinat­ion, as the immunization coverage rises.

The Ministry of Health should try to adopt a new national policy on contra-indications that will comply with the current WHO recommendations.

Upgrade supervision and in service practical training on BCG vaccination technique in both preventive medicine and curative medicine outlets.

The Ministry of Health should initiate activities that will aim at the proper supervision of the private sector' s immunization activities.

Establish a group of experts to ravl sa tha national policy on contra-indcations to immunization.

As a first step a random sample survey of. the immunization practices in the private sector can

I be done by using the I protocol made for this I purpose by .the review I team. I I

9. VACCINES AND COLD CHAIN

- 42 -

The Ministry of Health orders all vaccines and distributes them to various MOH 1 s hospitals, MCH centres and school health in addition of providing vaccines to Minis try of Defence under 1 scheme.

In the United Arab Emirates the cold chain must maintain vaccine quality for the entire national vaccine requirement in an enviroment where the temperature varies from as low as 1O 1 c to more than so • c, and where strong sunlight is present almost daily .

At the federal level both the MOH Preventive Medicine Department and the School Heal th Department share central procurement and storage facilities but operate their own parallel vaccine distribution and cold chain networks. At least one municipality operates an independent vaciine procurement and distribution system. • The Ministry of Defence and the National Oil Company, as well as the private sector have established their own parallel vaccine supply and distribution system.

At the peripheral level it is the responsibility of the individual immunization service provider to request. transport, and safely store vaccines .

The development of a national vaccine distribution network is a significant achievement .

9. 1 Estimation of vaccine requirement!

National EPI vaccine requirements are specified by the EPI Technical Committee of the · Ministry of Heal th Preventive Medicine Department. This committee consisting of the Assistant Under Secretary of Preventive Medicine, the National EPI Programme Manager, and the Technical Coordinator for Preventive Medicine meets at least twice yearly to estimate the EPI vaccine requirements.

Based on historical usage and the excellent vaccine distribution records, planned programme growth, changes in policy and other factors, vaccine requirements are estimated six months prior to the scheduled vaccine delivery dates.

The approved requirements of the EPI Technical Committee is processed by the Ministry of Health ' s Pharmacy and Supply Department which solicits international tenders from a list of recognized uaccine manufacturers.

The tenders are reviewed by the technical committee who agree to the procurement of vaccine requirements. The essential policy of the technical committee is to procure the most stable and potent vaccines available.

9. 2 Vaccine procurement and supply,

Vaccine producers are awarded one year contracts to supply vaccines for delivery in July/August and again in �anuary . This is done to accomodate the expected seasonal increases in demand .

9. 2. 1

9. 3

- 43 -

Only half of the Federal Ministry of Health vaccine requirement is procured through the MOH tender process. The remaining SO% of the MOH requirement is procured with and through the Secretariat General of Health -for Arab States of the Gulf.

In addition the EPI Technical Committee is authorized to procure vaccines locally in life saving situations.

Vaccine procurement specifications

The Ministry of Health has adopted the "Special Terms and Conditions for Vaccine and . Sera" of the Secretariat General of Health for Arab States· of the •Gulf as its vaccine procurement specifications (see Annex S).

World Health Organization and United States food and Drug Administration vaccine quality certification is required for all vaccines with verification by the government of the supplying country and a representative of an Arab Gulf State in the producing country.

While these terms are strict on vaccine quality certification, the shipping, 'transport, and delivery control· and evaluation terms are not sufficiently �lear and specific to insure the delivery of fully potent vaccines.

In particular the use of WHO Vaccine Monitor Marker Cards does not conform to the WHO Guidelines for International Packing and Shipping (WHO/EPI/CCIS/81. 4/Rev. 1). This has been confirmed in a recent examination of an international vaccine shipment.

The terms of delivery should specify dates which would avoid weekends and public holidays.

Vaccine Quality Control

Vaccines ar� not inspected or tested on arrival at the Central Medical Stores. As Vaccine Monitor Marker Cards · were not in the shipping cartons it is not possible to evaluate the temperature history of the vaccine during shipment or its subsequent storage.

Occasionaly suspect vaccines are sent to the original manufacturer for testing.

No other quality control measures are in use. Oral polio vaccine could be considered to be at the greatest risk, particularly in the absence · of temperature monitoring and under poor storage conditions. The heat stable measles vaccine currently in use might be considered at risk if recent verbal reports of measles in vaccinated children is confirmed.

- 4-4 -

9.4 The central level cold chain

tnternational shoipments of vaccine arrive at Abu Dhabi International Airport ·where they are stored in an airport cold room pending customs clearance by · a private customs clearance agent contracted · to the Ministry of Health. The maximum clearance time was stated to be three days for shipments arriving on Thursdays.

Upon customs. clearance the vaccines are transported to the Federal Government Central Medical Stores in Abu Dhabi .

9.4. l The Central Stores

Vaccines are stored and distributed nationally from the federal central stores .

• BCG, DPT, and measles vaccines are stored for the most part in their unopened shipping containers, on the floors and shelves of a spacious (estimated 1260 cubic meter cool room) . This cool room is used primarily to store heat liable pharmaceuticals, sera and vaccines. The multiple refrigeration units provide a relatively low volume flow of cool air, jllowing wide temperature differentials throughout the storage space. The. cool room has non-sealing swinging double doors which add to 'the elevated temperatures in the door area (14 ' C) .

The cool room had no thermometers, thermometers, alarm systems, or othr temperature monitoring. . The temperature vaccines were measured at between 10' C and automatic standby generation was in service.

recording form of

of the 14 ' C. An

Vaccine stock . records confirm that some vaccines (measles and BCG) have been stored in these conditions up to their expiry date, possibly for up to two years.

As the loss of vaccine potency is a continou� cumulative process, the storage of vaccines under these conditions is a particularly fragile. link in the cold chain"

- 45 -

Oral Polio Vaccine is stored in three chest freezers of approximately 1000 litres capacity each. The freezer temperatures were in the range of -lS ' C to 18 ' C. These freezers needed defrosting and other maintenance/

Table 9. 4 : MOH CENTRAL VACCINE STORES EQUIPMENT

I I I I I Refrigerator/ Size Working ITemp. Alarm Years IDeftost-I freezer Cu . Yes/No l record? Yes/ in , ing? I cold room mt. Yes/No No service Yes/No I

- I Q 1 cold Room 1260 Yes No No 8 yrs No

I I I Freezer 1000 Yes No · No 1 Yes I I Freezer 1000 Yes No No 3 Yes I I IF.reezer 1000 . Yes No No 3 I Yes I I

NB. All refrigeration e�uipment in the U.A.E . is 220/240 volt/SOHz.

9 . 4.2 Vaccine Stock Control

Stock records were computerized and enabled excellent stock control with almost no overstocking or understocking.

The use of computerized . stock control facilitates the determination of national supply requirements and serves as a stock management tool.

Monthly stock movement printouts are use� by the MOH EPI Technical �ommittee to analyse Medical District activity .

Temp in ' C

+12 ' C + tO' C

- 18

- l S

- ie

I I I I I I

to : J

- 46 -

9. �.3 , Central level vaccine distribution

9 . 4 . 4

9 . 4 . S

· The Central Medical Store supplies . vaccines to the Preventive Medicine Departments of the 8 Medical Districts of the U.A � E. In addition the stores provi�ed vaccines to several hospitals and the School Health Stores which has its own parallel national distribution network.

Vaccine is transported in "picnic boxes .. with minimal cold packs . The packing of vaccine shipments as described by staff at all levels does not conf.orm to good cold chain practice. No thermometers , or Vaccine Monitor Marker Cards are used during the shipment of vaccines.

Even though travel times are normally under two hours in ' the u � A . E. vaccines must .be considered to be · at risk. As the loss of vaccine potency is a continuous cumulative process the transport of vaccine under local conditions is a particularly fragile )ink in the cold chain.

Central level cold chain supervision

At the pret ent time there is· no central level cold chain supervision to provide technical supervision and training as well as cold chain quality monitoring at the Medical Districts and the immunization service outlets.

The Training of central level cold chain staff

Training is a continuing process to enable manage-rs. technicians, inspectors, and · other staff to carry out their duties and responsibilities effectively . All personnel dealing with vaccine management and h�ndli9!1' need training in current practices and methods and need to be kept informed of the latest de�elopments in cold chain . technology.

The staff directly concerned with vaccine• management, cold chain, and logistics, have received no specialized training either in-country or abroad .

- 47 -

Table 9 . 4 . 5 : MOH Preventive Medicine Deeartment Central Vaccine Distribution

I Vaccine Doses Distribution 1 9 8 5 I I

l'DT I

! Medical District IBCG IOPU J DPT ! Measles I

I I I I I I IRas Al Khaima 8, 500 1 22, 000 1 20, 000 I 3, 500 I 3, 390 I I I I I I I . I I I I I I l I I I IAbu Dhabi 1 20, 305 1 3 5,000 1 35, 000 I 7, 800 I I I I I I 1 I I I I I I I ] I I I I I I I I I Sharj ah I 9,750 [ 29, 000 l 29, ooo I 3, 7 00 1 10, 000 I I I I I I I I

2 6, 990 1 I

Al Ain 8 , 960 23,090 2 , 999 4 ,000

Um Al Quwain 1, 500 5, 000 4 , 500 6 00

Dubai 10, 500 1 9, 000 8 , 000 2, 400 2,000

I I IAj man 2. �00 1 10, 000 7,000 2, 000 300 I I

I I J Fuj aira 3 . 77_0 I 9, 990 10, 400 4, 900 I I

I I

! School Health �1. 000 1 I I I I l IOttier 3, 010 I 2 1 10 I I

I I I I ( Expired stock 6, 100 I 1 16,500 I I I I I

I I I I I I I ! Totals 1 95,895 1 156,982 1 136, 990 1 44- ,400 I 19, 700 I I I I I I I I

- 48 -

9 . �� District level co ld cold chain

9 . 5 . 1 . Federal MOH Preventive Medicine Departments I '

Each medical district requests its vaccine supplies from the central Medical Stores in Abu Dhabi , and arranges to col lect and transport the supplies using their own vehicles and personnel .

On receipt , the vaccines are stored in one · o r two domesti c refrigerator/freezers in the Medical District Preventive Medicine Department .

In the '11istrict vaccine stores reviewed the vaccine packing was not in accordance with current good practices . Refrigerators were either over packed causing e levated temperatures in the lower part of the cabinet , or under packed and without cold dogs all�wing �ide swings in refrigerator temperature with use.

Some 75� of the refrig�rators seen at this l evel were in working order though many were not of an appropriate type for the storage of vaccines . "Frost free" refrigerator/freezers are particularly unsuitabl e· for cold chain purposes . "Al l of the top loading deep freezers had frost layers in exces� of 4 cm. SO� of the refrigerator/freezers needed defrosting.

Half of the refrigerators and none of the freezers had thermometers. For the most part the thermometers were not placed near the vaccines and did not provide an accurate indication . of vaccine storage temperatures . Daily temperature recording is carried out in most stores where therrmometers were in use . No Vaccine Monitor Marker cards were. in• use at this l evel .

The vaccine storage temperature field measurement results were:

Refrigerator storage [f4 'C to +a •c1

Less than 4 ' C = 20�. : •• 4 'C to a • c = �o� : a • c to 14 ' C = 40�

.Freezer- storage [-15 ' C to -25 'C]

Colder then -a • c = o� i Between -1 • c and -4 ' C = 100�

Some frozen DPT was found in one district stores . This was caused by poor vaccine packing in the refrigerator .

9 . S . 2

9. S . 3

9. S. 4

9.S. S

- 49 -

Vaccine stock control

Vaccine stocks at the time of the field visits appeared to be adequate for 2 weeks to 3 months operations . Stock records were well maintained and up to date. even though differ·ent record keeping systems were implemented in each district reviewed.

Stock control appeared to be well managed with no over or under stocking in terms of •district programme .needs. In two Medical Districts stocks. were excessive with supplies available for 6 months to I S months operations . At the district level good practice would limit stocking levels to a maximum of 3 months supply.

Vaccine distribution

The Medical District Preventive Medicine Departments supply vaccines to MCH centres • . clinics. hospitals. and other EPI outlets on request.

Vaccine is transported in " picnic boxes" wi'th minimal cold . packs. The packing of vaccines does not conform good cold chain practice. No thermometers or Vaccine Monitor Cards are in use during vaccine transport .

Even though travel times are relatively short within each medical district at less than 2 hours. vaccines must be considered to be at risk. As the loss of vaccine potency is a cumulative and continuous process the transport of vaccine under local conditions is a fragile link in the cold cha_in.

The training of District Level cold . chain supervisors

The medical district EPI - staff as well as the district inspectorate have received no specialized training in EPI and c'old chain management. It is an achievement that EPI operations are as good as they are in spite ofp

this serious training g ap.

Dubai Medical Services Central Vaccine Supply Operations

Dubai Medical services operates its own procurement. storage. and distribution network.

On clearance from Dubai International Airport a receiving inspection for the presence of cold packs or dry ice is carried out· before acceptance of the vaccine consignment.

Vaccines are then transported to the Dubai Medical Complex vaccine stores. The vaccines are unpacked into

- so -

a purpose built cold room (approx. 30 cu. mt . ) . This well maintained cold room uses dual refrigeration units and is backed up by a standby generator. The temperature is monitored using built in thermometers and was in the range of 2 1 c to a • c .

Table 9.5.5 : Dubai Medical Seruices Control Vaccine Stores Cold Chain Equipment

I I I I I I I Refrigerator I Size I Temp. I Alarm I Years I Defrost-I freezer I cu. ! record? I Yes/ I in l ing? I cold room l mt. I Yes/No I No l seruice I Yes/No I I I I I I J I I I I I I Cold Room 1 36 m3 I Yes I No I 3 yrs I

I Refrig/Freez. I 350 Lt. I No No · I 3 I No I I I I I I Refrig/freez. ·1 350 Lt. I No No I 3 t No

) Standby Generator Auto

I I I What is I I temp. I l in ' C? I I I I 1. 1 +2 to +8 1

+4/-6 I I

+47-6 I

NB. All refrigeration · eqaipment in the U.A.E. is 220/240 uolt/SOHz.

Polio uaccine is stpred in the freezing compartment of a domestic "frost free" refrigerator/freezer at -7 1 C.

Vaccine distribution is much the same as in the federal system. No Vaccine Monitor Cards are in use.

9.6 Cold chain at the seruice deliuery leuel

All immunization deliuery centres collect their uaccines from the district uaccine stores . The uaccines are unpacked into domestic refrigerators.

Of the refrigerators surueyed at EPI outlets 8 8'%. were in working order. howe·uer only 55% had thermometers inside. Many were in direct sunlight.

Table 9.6 :

The uaccine storage temperature field measurement results were :

Refrigerator storage (+4 ' C to +B' Cl,

Less than 4 1 C • 10% I ** 4 1 c to 8 1 C = 36% I a • c to 15 1 C = �4%

9 . 6. 2

- 5 1 -

Training of EPI outlet personnel

The staff providing immunization services are highly skilled and caring people who have not received training and instruction in the appropriate methods for vaccine handling and in good cold chain practice.

In addition to training and periodic refresher training, vaccinations and nurses need the proper tools and equipment and the training ·that goes with them to insure the high quality immunization delivery service the system is capable of providing.

I P R O B L E M S I

VACCINES AND COLO CHIAN

R E C O M M E N D A T I O N S STEPS TO BE TAKEN 1-------------- 1--------------------------- ---------------1

1 . I

Cold chain and vaccine hand- • I ling operations are weak at I all levels. Standard operat- I ing procedures ara not properly I implemented, supervision l s I . inadequate, monitoring and evaluati on ara not performed

a- Recruit and establish a strong team to cond uct extensive practical training in cold chain operation and vaccine handling for all personnel involved in tha operation, usa and supervision of tha cold chain, This would enable a major improvement in vaccine quality assurance.

b- In order to maintain tha improved operation of tha improved operation of tha cold chain, it is recommend­ed that, on tha completion of initial staff training. tha training team ba designated as a supervisory team to make supervisory visits to all regions.

c- Tha improvement of standard procedures and methods for the operation of tha cold chain at all levels would assist in training, operation, and planning aspects of tha immunization programme.

d- Tha usa of vaccine monitor markers and other chemical indicators, along with temperature record­ing in a systematic way .

a . Datarmina tha training requirement.

b , Recruit training staff c . Train the team. d, Schedule and conduct

training.

a . Develop supervision check-list.

b . Recruit staff for supervision.

c . Schedule v is its to all centres.

a , Defina a nd specify procedures.

b , Train staff to fol low procedures.

c . Circulate guidelines,

a , Deve lop a plan for cold chain monitoring and evaluation .

b. Procure indicators and markers.

c. Implement plan. d. Conduct periodic review

and improve the col d chain

VI N

1

P R O B L E M S

2 , The vaccine storage equipment used at the Central and District Vaccine stores l s not appropriate, and puts vaccines at risk . Ice making capacity is insufficient to support the vaccine transport require­ment.

3, Vaccine are subject to temperatures higher and lower than thosa recommended, with the risk ·of reducing vaccine pot�ncy.

VACCINES AND COLD CHIAN

R E C O M M E N D A T I O N S

a , Tha usa of a seperate cold room for tha storage of vaccines at the Central Medical is recommended ,

b. The replacement of domestic refrigerators at District Vaccine stores with Ice Lining Refrigerators is recommended,

c , Ice-making capacity should be increased at the Central and District stores,

a, The use of frozen cold pack s and vaccine carriers during the immunization session would prevent damage to vaccinet.

b , Cold boxes for both transport. maintenance and emergency use would improve the cold chain dramatically.

c, Additional cold packs. both for cold boxes and refregerators, would improve temperature ability .

d , If unutilized space in refrigerators were filled with cold packs temperature stability would ba enhanced and storage time in the hot season or the event of electricity or equipment failure would ba increases,

STEPS TO BE TAKEN

a . Determine the equipment , required.

b. Procure tha - equipment c , Distribute and install

tha equipment , d , Evaluate the cold chain.

a. Determine the requirements cold packs, vaccine carri­ers cold boxas.

b, Procure cold chain accessories,

c. Train staff in the usa of cold chain accessories.

d , Distribute these items ,

a , Monitor and evaluate the cold chain.

---------------------------- ---------------- · VI w

- S4 -

10 . DISEASE SURVEILLANCE

10 , 1 Reporting of Notifiable Diseases

Disease surveillance and control activities are guided by the Federal Law No. 27 of 1 981. Routine periodical reporting of notifiable diseases is the main method used for data collection. This routine method is at times reinforced by sample disease surveys, outbreak investigations and others.

The maj or sources of data are the health institutions, population screening programmes, case finding, sample surveys, and MOH and municipality laboratories.

Although the procedures and methods used in the disease surveillance programme are to a certain extent inadequate for meaningful scientific analysis and interpretation, the available data could still be utilized to reflect the current situation in the country.

The aforementioned inadequacies are related to : - Shortage of various resources and facilities

Lack of a coordinating unit at central level - Unawareness of the importance and magnitude of such

services among health managers . - Limited inter-departmental as well as intersectoral

cooperation in the relevant fields of activities.

The existing system of disease reporting consists of regular monthly reporting from the periphery (health units) to the Medical . Districts (Department of Preventive Medicine) , which in turn reports to the Department of Preventive Medicine, Ministry of Health. The list of diseases on the notification forms appear to be large but all EPI diseases are included in that list. Notifiable diseases have to be reported immediately and further action is taken by the Department of Preventive Medicine at the Medical District. The compliance of the reporting units appears to be fair but not complete.

It was clear that apart from communicable diseases reporting, no routine reporting for non-communicable diseases exists.

10 . 2

- 54 ( a ) -

EPI target disease1

Apart from the information obtained through the routine reporting. no special surueillance is carried out for the EPI target diseases . Howeuer. in the Annual Report -of the Department of Preuentiue Medicine. Ministry of Health. the EPI target diseases are presented separately. attention giuen to the trends of these diseases .

The following graphs illustrates the distribution of the age specific incidence rates per 100. 000 population for the six EPI diseases separately.

' - The cooresponding tables for the graphs are included

in the 198 S Annual Report .

- NNT is not reported separately because of uery low incidence.

aJ I.

•

n•

••

I l l

...

. .. .,. ... •• • • • • u

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,.,

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'1rl ., ..... '"' • ml IWLt.a

11■1 .... ,., ....

UL

••

••

...

... ..... cu

,u

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..

w •• ., .. . ..

.... ..

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11,c .. L\11.11 '"' , 1"1 1\1,4.LI

. . . . . .

. ... . ... . ...

••

, .

, ... ,..,

·­

•• ... -. , . .. •• -

, . -

••

-

-

• •

.. -

I■

-• •

Annual Incidence Rates for Poliomyelitis, Whooping cough and Measles by age group

1981 - 1985

� .

•••

1111 &-1, ll'C'l•rJ<C A&Tl:I IA.1.11.I Cit M� n &CC c,_ ro•

n,c "'-II.I ,,.., 11w ,.,.. ,,., "'"'.._.

....

. .......... ....._. ·-·-· ·----- . . __. ... .... • •• , ... •••

V, \.Tl

•

• • •

II

• ••

•

..

i,

• II

• ·•

n,r. ·""""'· ll'IClv,'.J<(C ... m 141.lll.t lll' Tl,au diu1111 u &C& '"°"' ,-

"" ,., .... .... . ... I IUJLr.1

IU

11•

.... , .. IU

... tu

.. •• ,. ... ... ... ... ,.. IJ

... ...

""

'"' """"·" •IIODCl'CC ... ,u IA.MLICII� Tl1p1'CA■l •N• • d11 lu.&.t-1

,n .. :>na " .cc c•- ,_ TUC 1'CAa.l • .,. • 011 1\1.A.U

. .. .... -----��- , ..

II•

.... '"' ...

,.. u u

Graph 10 . 2 Annual Incidence Rates for Tuberculosis Tetanus and Diphtheria by aga group

1981 - 1985

•••

n,c •MV•L ll'CIUC/ICI IAft:I ...... u llt 11nrT1Jt.111•. n &CC•c,_ lo,,,

e1i• '"'" ... . ..... II.A.'-!

. ...

. ..

. ...

VI 0\

10. 3

- S7 -

EPI diseases reduction

· It has become evident that from the .routine reporting of the EPI target diseases over the last five years there has been disease �eduction in all diseases except Diphtheria (See Graphs 10. 1 and 10. 2). As the immunization coverage increases this situation requires more �areful assessment and evaluation.

10. 4 �aboratorie�

There are 8 laboratories at the Department of Preventive Medicine at the Medical District level. Their role is for screening expa.triate workers coming into the country . In case of an outbreak these laboratories are used for simple tests. More elaborate te�ts are referred to the municipality laboratories and hospitals. However, these services are not adequate to meet the actual needs of epidemiological investigation.

10. S Future strategies For Epidemiological investigation and disease control services

Future strategies for improving epidemiological investigation and disease control services have already been ·considered by the Ministry of Health. These can be summarized as follows:

- The reinforcement of the existing strategies of the Department of Preventive Medicine especially with regard to manpower development and improvement of other resources at central, district and periperhal levels.

- The establishment of a central unit, at the MOH, for disease surveillance and control in order t� implement, develop and supervise the statea strategies.

- Collective efforts to develop and design relevant and practical notification and reporting forms.

- The application of more scientific methodologies for collection, analysis and interpretation of data in order to define parameters and evolve locally applicable indicators .

- Up-dating the list of notifiable diseases accordin� to the local U . A. E. situation and designate notifiers for each Medical District. ·

- The development of short · and long-term plans for disease surveillance which, specify clearly the setting of disease control targets .

- 58 -

The assessment of cost effectiveness of such programmes.

The frequent and regular feedback of information to health personnel at various levels especially to those working in the closely relevant disciplines such as clinical medicine. paediatrics. microbiology. pathology and biostatistics.

- The establishment of epidemiological investigation units in all major hospitals and initiation of epidemiological investigation at primary level units .

Further development and maintenance of lhe already existing screening programmes with special emphasis on certain categories of the population especially those coming from kno�n endemic areas .

The participation in developing continuing education programmes to promote case diagnostic abilities. especially those related to target diseases through well defined diagnostic criteria/procedures and the production of relevant guidelines for country-ta1ise use.

- Highlight the importance of community as well as institution-based studies and surveys related to technical. operational and managerial aspects of the various disease control programmes.

- Maintain inter-country contact and exchange of experience especially with neighbouring countries and countries of origin of the major immigrant populations in addition to the invitation of regional and international agencies and institutions. for cooperation and assistance whenever needed.

In the context of the development and implementation of . the aforementioned . strategies a qualified epidemiologist has been recently appointed ·at the Department of. Preventive Medicine. Ministry of Health.

10. 6 Field Observations

Although data on communicable diseases are dispatched regularly and on time from all health districts and facilities visited by the Review Team. these data did not appear to be readily available and in use at local level.

In 7 5-X. of the centres visited one person was responsible for recording and reporting disease.

- 59 -

At health facility level only 60� of the centres • visited, data on vaccine preventable diseases were

available. In those cases that data existed these were given by age but to a lesser degree . by 'immunization status of the child.

All in all it became clear that very little use of the recorded data is done for local investigation of disease patterns and/or for planning purposes .

I P R O B L E M S 1--------------1 1- The e�isting laboratories for I communicable disease I surveillance are inadequate ] for accurate diagnosis and I disease outbreak investigation. I 1 2- The poliomyelitis cases are I now diminishing and the l Diphtheria cases are affecting 1 older age groups than the I child population. I I I 1 3- In most cases EPI target I diseases are reported by age I but not the invnunization status I of the child . I I (-------------

SUBJECT DISEASE SURVEILLANCE

R E C O M M E N D A T I O N S STEPS TO BE TAKEN ------------------------------------- 1

The Ministry of Health should look into the I establishement of a central Public Health Laboratory I and the strengthening of the laboratories at the I Preventive Medicine Departments in the Medical I -Districts. I

It is essential that accurate d iagnosis of both d iseases it made in order to distinguish between wild virus poliomyelitis and vaccine induced poliomyelitis. For Diphtheria most of the cures are based on clinical diagnosis above. whereas accurate laboratory diagnosis will assist to develop the most appropriate strategy in coping with the e limination of tho disease .

A procedure should be established by which EPI target diseases are reported by immunization status of the child .

I In the context of revision of ! reporting forms for notifiable ldiseasos care should ba taken I to include immunization status lof the child . I 1-------------

I I I

0' 0 '

11. MOTHER & CHILD HEALTH�

11. 1 Introduction :

- 6 1 -

Mother and Child Health seruices are prouided by the Department of Preuentiue Medicine of the Ministry of Health. Mother Child Health centres are distributed throughout the country and offer the following seruices :

l. Ante-natal care whereby all expectant mothers are superuised and followed.:up till the 28th week of their pregnancy and then they are referred to the nearest maternity hospital for closer superuision in preparatiori for confinement.

2. Post-natal care whereby all mothers attending ante-natal care at the centre would go for post-natal check up during the second month following deliuery .

3. Child care whereby all children are screened for growth and deuelopment and a close follow-up of their nutritional status.

4 . Vaccination : All MCH centres prouide immunization to all children below 5 years of age.

5. Health and Nutrition Education : A heal th education programme is established in euery centre that . caters for pregnants, and child care posters, pamphlets, booklets, files and liue demonstrations are offered at the centre leuel.

6. Home Visiting, as such in urban and rural areas is generally practised by a health team working at MCH centres. Their job is to follow-up mothers in their homes on matters related to mother and child care.

Other gouernmental and semi-gouernmental outlets which prouided MCH care uary in their range of actiuities and degree of coordination with the MOH facilities include : Dubai Medical Seruices, Minis try of Defence Heal th Seruices, Petroleum Companies Medical Seruices and Ministry of Interior.

Voluntary organizations such as Women ' s Associations, Missionary hospitals and clinics are inuolued in uarious HCH actiuities. Recently efforts were made to enhance their role especially in the remote areas and in the field of heal th education and community participation.

- 6 2 -

11.2 Field Obseruations and Suruey Results:

By analysing the data of the home leuel suruey it was noted that the home leuel suruey included information on ante-natal and child �ttendances. deliuery distance of health facility in addition to some information about the extent of knowledge about the use of ORS.

Table 11.1 shows a comparison between urban and rual popualtion in the UAE as per the results of the suruey. 92% of pregnant mothers attended ANC in urban areas compared to 90.9% in rural areas. The auerage number of uisits ranged from 6. 3 times in urban to 4-. 3 in rural areas.

Hospital deliueries constituted 98% in urban areas and 92% in remote areas. The table shows clearly that home deliueries occur mainly in remote areas where 8. 5% of the mothers deliuer at home. Of these 4. '7% were deliuered without any professional superuision. where 3. 8% deliuered under the superuision of either a physician or a midwife.

The same table shows that no deliueries took place without professional superuision and 0.75% deliuered at home under superuision in the urban. Regarding child attendance at health facilities. 66.6% attended at least once with an auerage of 5. 0 uisits per child before reaching the age of one year old in the urban. while in rural 59.0% attended at least once with an auerage of three uisits per child before they reach the age of one year.

The auerage time needed for mothers to reach the nearest health facility was 12 minutes in rural and 11 . 3 minutes in urban.

Information collected on knowledge and use of ORS reuealed that 5 1.5% had knowledge about ORS. of whom 58.7% in urban and 62.5% in rural actually used ORS.

Table 11.2 shows that breast feeding is widely practiced in UAE both by rural and urban mothers for at least 8 months. including an auerage of fiue months of breast feeding only.

The introduction of solid food before .six months of age is higher in urban areas (76.1%) than in rural ( 66 .1) . There is still a tendency for mothers in urban and rural areas to practice both feedings at an auerage of four months of age.

TABL E : 1 1 . 1

ACTIVITIES

Ante-Natal Attendance

Deliuery

Child Attendance

Distance to health facility

Oral Rehydration Therapy

I I I

�CH - UTILIZATION HOME LEVEL SURVEY RESULTS

{OCTOBER 198 6)_

Percent total

Au , No . of Visits

Gouernment Hospitals

Priuate Hospitals

Home deliuery superuised

Home deliuery unsuperuised

Home deliuery total

Percent total

Au. No , of times weighted

Au , time in minutes

Percent of mothers knowing ORS

'-------:::....--..----�-�� I Percent of mothers using ORT I '---------------

ij R B AN

92%

6. 3 times

8 1%

1 7%

0 , 7 5%

1 . 42%

66 . 6%

S. O times

1 1. 3 min.

5 1 . 9%

RURAL

90 . 9%

4 . 5 times

6 5 . 2%

26 . 6%

3 . 8%

4 . 7%

8 . S%

59 . 0%

3 . 0times

21 min.

49 . 5%

3 . o times

6 2 . 5%

T able 11 . 2

BREAST FEED ING PATTERNS

BREAST FEED ING .

Breast feeding Average duration in months Average

Average breast only in months

Average solid food before six months with breast milk

Average in months beginning bottle feeding

U RBAN

8 , 2 months

5 , 1 months

76 . 11,

4, 1 months

RURAL

8 , 7 months

5, 1 months

66 , 11 months

4 , 11. months

°' �

PR O B L E M S

1- The standard of quality of service in MCH care is high but the accessibility of this servica 'to the rural areas is more or less limited.

2- From the cluster survey home . level it was found that e . s� of deliveries in rural areas took place at home.

0073T

SUBJECT MCH

R E C O M M E N D A T I O N S

Maintain and consolidate the high attendance to MCH services in urban areas and extend and improve them in the rural areas.

Ensure that professional attention of these home deliveries is provided.

STEPS TO BE TAKEN

! Extend provision of MCH l servtcas to includa peripheral !health clinics at the rural l areas, ' I I BY rendering MCH services to l the rural area these home ldeliverias can be identified l and followed up. I 1------------

t 0-VI

12 . 1 HEALTH EDUCATION :

12.1 Introduction:

- 66 -

. . The National Health Education programme for the UAE couers the community at large with special concentration on certain categories of the population mainly mothers and children wherby specific programmes are directed towards such categories.

12. 2 Methods and Media used in th UAE:

The methods and Media used in Health education ensure that the information · reaches each indiuidual in the target group :

- The methods attract the interest of the people.

- The content and purpose of new ideas are clearly understood.

Person to person education is giuen priority in the National Health Education programme in the UAE . The media used couer a wide range of facilities auailable in the country, such facilities focus on TU and radio programmes, books, posters pamphlets and booklets related to local health problem areas in the Community. Encouragement of field studies and deuelopment of pilot programmes where community participation is inuolued are giuen utmost importance.

The health education unit at the HOH prouides uideo tapes to the HCH centres, School Health Seruices and some hospitals . The uideo tapes are renewed and kept up to date at the central education unit which has facilities for dubbing, editing and reproduction, as well as limited facilities for production. A collection of 16 mm films is used for remote and other areas where uideo facilities are not auailable.

There is· a continuous production of uarious publications including books, posters, pamphlets and booklets related to local health problems. Special occasions such as world health day, child health day, mother • s day and other are used for wider circulation of such health education materials.

Table 12, 1,

HEALTH EDUCATION

KNOWLEDGE ATT, MOT HER URBAN RURAL

Knowledge about EPI Target Disease 6S . 2S 58 , S'X

Immunization Schedule 76 , 7'1 78 , lS

Source of Knowledge TV 32 . 8%. 3 7 . l'X

Radio 9 . 01 2 , 3S

Newspaper 20. 4%. 2 . 8�

Health Staff 3 9 , 0" 401

Others 26 , 6 1 1 . 4S

.. iteracy S TOTAL 72 , 3'1 3 4 , 7%.

- 68

12 :3 Field observation and field results

In assessing knowledge -and attitudes of mothers fon.,ards immunization programmes ( table 3b) it became clear that the majority of urban and rural mothers knew about target diseases and immunization schedule.

The main sources of information was the TU 32. 8% in urban and 3 7. 1% in rural and heal th staff 39 . 0% and 40% respectively. Newspapers play,d an important role in urban areas 20 . 4% in contrast to rural areas where it only constituted 2. 8%. It seems that literacy status of the mothers c�uld have played an important role in the stdndard of knowledge and attitudes of the mothers where 72 . 3% were literate in urban while only 34. 7% were in rural areas.

P R O B L E M S

1- It i s clear that tha Health Edu cation Unit at the Ministry of Health requires further development, strengthening and support.

2- The review team felt that the rural areas need more attention in person to person health education

SUBJECT HEALTH EDUCATION

R E C O M M E N D A T I O N S

The Ministry of Health should allocate sufficient personnel and funds in order to ensure a more comprehensive and extended health education programme.

The outreach/mobile teams and rural health clinics should be designated for the person to person health education .

STEPS TO BE TAKEN

An initial assessment/study of the needs and priorities in

( Health Education should be made lby the Ministry of Health. I I I - Provide adequate training and I orientation for these health I workers, I - Strengthen the health clinics I and outreach/mobile teams to I meat the needs, I 1-------------

I

0' \0

- 70 -

ANNEX 1.

Agenda for EPI Field Evaluation Workshop

Tuesday 2 1 / 10/8 6 - Dubai

1. Jxpanded Programme on Immunization

Background and Global overview Recent Advances in EPI

Prog�ess in EPI in United Arab Emirates

Role of International Agencies in EPI

2. Evaluation in EPI

Principles of Reviews and cluster sampling

- Evaluating and Assessing the cold chain

- Details of present review health units coverage evaluation using cluster sampling

3. Practical Exercise

Dr . N . A . Ward

Dr. A. Nur

Dr. A . Makki

Dr . N . A • Ward

Mr. Allan Bass

Dr. M. Uoniatis

- .7. 1 -

Annex 1 (continued) : List of participants in workshop and Field Review

Abu Dhab,!

1 . Dr El Sayed Mohamed Balasi 2. Awni Abdul Qadir 3 . Dr Riyad Sahwani 4. Adnan Asa ' ad

.Dubai

Ministry of Health 1. Dr Khalil Sherif Dawood 2. Wafaa Abu Ali 3. Sahar Khalil Beshir

Department of Health and Medical Seruices 4. Dr Suhair Badr El Din 5. Takrah M. Badri

Sharjah

1. Dr Lana Ali Badr El Din 2. Dr Ibrahim El Qadi 3. Dr Abdul Ameer Hameed 4. Dr Aliya Ali Abulela 5. Hanim El Haddad 6. Mahmooda Yasmin 7. Aisha El Khateeb

.�man

1. Dr Mohammed El Taweel 2. Dr Sumaya Abdul Qadir

Um Al 2,uwain

1. Anita Lawerence 2. Saad

Ras Al Khaimah

1. Dr Yahia Haddad 2. Dr Wafaa Abdul Hameed

Al-Ain

1 . Dr Mohamed Osman Hassan 2 . Muna Abdul Qadir 3 . Ismat 4. Suad

Fujairah.

1. Dr Fuad Al Talyaw1 2 . Dr Mahdi Suliman 3. Dr Samia Eleiwa

- 7 2 -

ANNEX 2

Members of the national team

l . Dr . Abdel Moneem Nur - EPI Manager . U .A. E .

2 . Dr . Ibrahim El Kadi - Medical Officer. Kalba Hospital

3. Dr. Khalil Sharif - Director of Preuentiue Medi cine , Dubai

4 . Dr. s . Bdlacy - Director of Preuentiue Medicine, Dubai

S. Dr. Lana Badreddine - Director of MCH. Sharjah

6 . Mr . Awni Abdel-Kader - Head of Communicable Diseases . Abu Dhabi

7 . Mrs . Huda Shaheen Kanaan - Technical Coordinator, Preuentiue

Medi cine, Abu Dhabi

Members of the international team

l . Dr . A . Hjian - WHO Consultant, EMRO

2. Mr . Allan B ass - UNICEF EPI Consultant , GAO

3 . Dr . A . Makki - UNICEF Officer, GAO

4 . Dr. Ni ck Hard * - WHO Aduiser , EMRO

s . Dr. Mi chael Uoniatis - WHO Consultant, EMRO

(Team leader and Rapporteur)

• Participated from 1 8 to 22 October 1986 only.

ANNE X 3

--�FRI DAY

( 17 ) Arrival of Team L�ader

(24) Draft report (National

°

level)

( 31)

Fiold visits

( 7 ) Final Draft of the report

EPI/PHC revi�w - UAE TIME SC HEDULE OF MAIN AC TIVITIES 18 OCTOBER to 10 NOVEMBER 1986

I SATURDAY I SUNDAY I _______ I ______ _ I I 1 (18) 1(19) !Preliminary !Meeting with !briefing of Team I Dr. l'\Jhaideb !Leader by Nation- !Finalization of l al Authorities l the overall plan )Arrival of T eam l ot evaluation, Members I

(25)

I I '-------

I MONDAY I TUESDAY I I _____ _ I I 1(20) 1 (2 1 ) !Briefing of the IOna d ay workshop !National and f for Supervisors !International l in Dubai !Team Members. I ! National Level I I Evaluation, I I Departure for I Return to I pubai I Abu Dhabi I I ____ _ I I

WEDNESDAY

(22 ) Field Vis i ts �nd . Cluster Survey

Abu Dhabi

1 (27) 1 (28) (29 ) Field

1 (26) Visits and I Cluster I Survey __J,_·· __

( 1 )

and Cluster

(8) Discussion of the Recommendations

I I I I I I I I _______ I ______ _

(2)

Survey

1 (3 ) 1 (4 ) l (S) I I I !Compilation and !Data Analysis I I I l

Drafting

�------ 1 _______ 1 _______ � -------(9) 1 c 10) I I Presentation of ! Departure I I the Draft Report J of the Interna- I I to H, E, the ltional Team I I Minister of ! Members I I

JHealt� I I I _______ I _______ I I 1 ______ _

THURS DAY

1(23) !Field Vis its and J Cluster Survey I I I I IAbu Dhabi I '-------1 I ( 30)

(6)

the Report

.... w

I

ANNEX 4

CLUSTERS SELECTED BY URBAN/RURAL AND MEDICAL DISTRICT DISTRIBUTION

I !CLUSTER URBAN AREAS CLUSTER RURAL ( REMOTE) AREAS !NUMBER NUMBER I

Abu Dhabi Abu Dhabi I I

1 . Near Sheraton Hotel 1 . Jurn Yafur I 2 . Next to Abu Dhabi Co-operative 2 . Al Khatan I 3 Near Ministry of. Health 3 I Al Marfa ' I 4. Next to Batin Palace 4. Bedaa Zayed I 5 . Al Mushrif Park s . Bedaa Metawaa I 6 , Next to Driving License Oftice 6 . Ghiayathy I 7 . Mossafah (upper left corner) 7. Samha I 8 . Mossafah ( third street in the I

middle) I I

I I I I I Al Ain I Al Ain I I

9 I Al Giemy 8 . I Al Khora I 10 . I Central Al Ain 9 . I Wadi Al Sagia I 11 , I Al Mutarad 1 0 . I Al Wajan I 1 2 . I Al Muqam 11 . I Al Karah I I 1 2 , I Al Shoeweib

0073T

ANNEX 4. C continued).

Dubai Dubai

1 3 . Al Ras • 13 Al Khawaneej 14 . Al Hamriya IS . Central Regga 1 6 . Al Mussala 17 . Al Mateenz. 1 8. Port Said East 1 9 . Al Hamriya East 2 0. Port Said Central 2 1 . Rashidiya

I ' I I

I I I I I Sharjah . I Sharjah . I I I I I 22. I Al Heera 14 , I Al Khadeera I 2 3 . I Al Manakh 1 s . I Nazwa I 24. I Abu Shurgara 1 6 , I Thkaba I I 2S . I Samnan 17 . I Al Hamrya I 26 . I Al Khalidia 18. I Wadi Al Helu I I I 19 . I Al Zaid I I I I I I I I

I I I I I I Ajman I I ' I I I I 27 . I Centre of Social Affairs I I

I I I I I I I I

I I I I I

I I Umm Al Qawain .• 1 um Al Qawain I -.:i

I I I

I I VI

..... I 28 , I North to Mussala Roundabout 20. I Bayata I I I I I l I I I

ANNEX 4( continued)_

Ras Al Khaimah Ras Al Khaimah

29 . East of Kuwaiti Hospital 2 1 . Al Darah - Shaam • 22 , Dhaya 2 3 . Ouzon 2 4 . Al Khuzam 2 5 . Al Hamham 26 . Dafta - Masafi

I I Fujairah Fujairah I I 3 0 . East to Safaad 27 . Al Bethna I 28 . Wadi Al Hayl I 29 . Al Akamiah I 30 , Al Halaa I

ANNEX S •

- 77 -

Technical Conditions for Vaccine and Sera for the Arab States of the Gulf Revised ·

,1 9 8 5.

1. Goods supplied must be strictly in accordance with the specifications and the original samples supplied to S. G. H. with the offer. and accepted by the technical committee.

2. Any deviation from specifications and/or any change in the source of supply, the concerned country will reserve the rights to reject the goods and claim the damage.

3. The validity of every item should clearly be indicated in the space 'of Product I s · validity on each page. All i terns should carr.y date of manufacture, and date of expiry beside lot OR batch number which should be clearly indicated on the inner label and outer packing as well as on the invoices of goods supplied,

4. The specifications mentioned are minimum requirements and t-he · committee has the rights to choose higher quality.

S. Full details with regards to packing, period of delivery. and country of origin should be mentioned in the offer.

6. The company is asked to mention the number of units per pack for export in the special column �or each item.

7. All official preparations must comply with official standard of latest editions of International known Pharmacopieoas as e . P . • B. P. CC. - U. S. P., etc.

8. The shipping documents of each shipment must be accompanied by a certificate of origin. full specifications and methods of analysis certificate issued by known laboratory. � � Such certificate should be legalized by any Arabian Gulf Consulate or Diplomatic Rep�esentative in this country. Such documents should also give the full name and address. of manufacturing firm as well as the serial batch number of products and its confirmity in all technical aspects.

9. For non-pharmacoepeal products authentic samples of raw materials to be analized should be supplied .

10. The supplier must print the letter (S. G.H. ) on the label of the outer and inner packing of each individual unit of packing for each item.

11. Any objection from the company to any term , conditions and /or specifications , should be mentioned either in the remarks column of each item or in the covering letter.

_ 78 _

Annex S (continued)

No objection means acceptance of all terms. conditions and specifications and company will have to fulfill with requirements.

1 2 . Range of storage temperature of each item should be mentioned in the remarks column.

13. All goods supplied should satisfy WHO and FDA requirements.

1 4 . External of each unit pack should carry the following: Name of manufacturer. Trade name, Generic name, Strength, Manufacturing date, Expiry date, Batch or lot number, Storage temperature and conditions.

IS. The company should submit with the offer a copy of license from l'Ocal authorities to the company to produce and sell the product in the country of origin. The certificates should be legalized from one of the Consulate Generals of any Gulf Embassy in the country of origin.

1 6 . At delivery. every item should specified storage temperature for goods will be rejected.

be delivered at the that item, otherwise

17. Shipment should follow WHO requirements for packing, wrapping and storage during shipping.

1 8 . Delivery of all goods for all countries is by air-mail whether warehouse to warehouse or to airport.

19 . Each country has the right to analize any shipment and result of analysis is accepted.

20. Cold-chain monitor should accompany every carton delivered.

2 1 . The supplier must comply with Israel Boycott Clause and regulations. He must submit with his offer a certifica,t6 from Israel Boycott Office confirming that his company ·1s not on the black list. A similar certificate should be submitted with 'the goods on supply. Should any company • s name appear on the Israel Boycott list at any time, before signing the supply contract, any awardation, notified or otherwise will be void.

I

- 79 -

.ANNEX 6 IMMUNIZATION CARD

� �� . . IMMVNIZATION CARD

I alr2�

r I [ I 1 I�· r;)J .---------':....::....--=--=------....;.,_-I I�· .:,tt.

(!=====-,-�-----' ,�====:::::::, J;:.

��I •� �I i)--_; � .w, HJwtl µ1_,. .JI � �.J

·[IJITJITJ

o:J[IJ o::J[IJITJ ITJ[IJ ITJOJCD [TI[TI ITJ[TICD [TIITJ [IJITJ[IJ [I]OJ ITJOJITJ

[JJ[JJ [JJ[JJ[JJ ..._ -

, U..-\JJI r'II _ �I _ Jt.!1.1) -=-JI tl,-llJI �1.,J u-o &I. � JJ';'I ,.__u � ( '-'�1 - �I - j'IJll - JJli11 �� L:t,;.Y ��• � ' 4 .;. 1)-i. � .;J1., •.il+-,: JI •�I •� �I J�I ��., �

. � �'

APtU 11mm IMMl!DrAtaY

• DPT, rouo

FIRST DOSE l!ND OP 2tm MONTH OP AGI!

SECOND DOSE END OP ffll MOtffH OP AGE

n«RD DOSE END OP ffll MONlll OP AGE

• MEASLES END OP mr MONlll OP AGE

• MEASLES MUMPS END OP lffl{ MONlll OP AOE

• DPT, POI.JO (Booster) END OF 11TH MONlll OP AGE

CM 15/15

: cl

I

•� 14,ll -t - tl,111 .

:JI---AYI �, �• •

�· �· � __.,, �,.. t,-1.I.JI �I � ��,.. _,.J..Jl �I � ��,.. .:,.Wal >---+-211 � I . - .

.,.s.. .,..w, .,......m JLJ. ..ate, � . :� JL-J, �• .

� v,,UII �I J,X.... � � ,..

- 80 -"

ANNEX 6

POSTAL REMINDER CARD

• • • .. • • • . • . . . . • •• • . • . • . . .:JJ.a. .,�, �.,t

t:.�'il J� .. . . . . . . . . . . . . . . . . . J I

� _,... .u � $._,. .:,I � r-Jla.11

· "'�'