IMMUNIZE AND PROTECT YOUR FAMILY

Volume XXIX, Number 1 February 2007

In thIs Issue:

PAN�AMERICAN�HEALTH�ORGANIZATION

1 UpdateonMeaslesOutbreaks1 UpdateonInfluenzaVaccination3 PneumoniaHospitalizationin

ChildreninUruguay5 VaccinationWeekintheAmericas5 RevolvingFundVaccinePrices,20076 RubellaEliminationintheAmericas7 AFPandMeasles/RubellaIndicators,

2006

See INFLUENZApage 3

Update on Influenza Vaccination in the Americas

Influenzaisaviraldiseasethatstrikesmillions of people worldwide andcauses approximately one milliondeathseveryyear.However,manyofthesecasesanddeathscanbeavoid-ed through the use of safe, highlyeffective vaccines. The 56th WorldHealthAssembly,heldinMay2003,urged Member States to increaseinfluenza vaccination coverage inall high-risk groups, and to achieve50% coverage in people aged >65yearsby2005and75%coverageinthispopulationby2010.In2006,thePan American Health Organization(PAHO)’s Technical Advisory Group(TAG) on Vaccine-preventable Dis-easesrecommendedyearlyseasonalinfluenza vaccination for childrenaged6-23months,healthcarework-ers,chronicallyillindividuals,andel-derlyadults. Furthermore, it recom-mended to strengthen surveillance,generate coverage data, and docu-ment lessons learned,whichwillbeusefulintheeventofapandemic.

To determine the current status ofinfluenza vaccination in the Region,PAHOasked immunizationprogrammanagersintheAmericastorespondto two surveys – one created byPAHO and one from the WorldHealth Organization (WHO) – onseasonal influenza vaccination andfutureplansforapandemic.

Forty-five countries and territoriesrespondedtoeitheroneorbothsur-veys:19fromLatinAmerica,22fromthe non-Spanish-speaking Carib-

Update on Measles Outbreaks in the AmericasEndemic transmission of indigenous measles virus was interrupted in the Americas in November 2002.However,sporadiccasesandoutbreaksassociatedwithimportationscontinuetooccur.[1]Inthisarticle,wedescriberecentmeaslesoutbreaksinthepost-eliminationerainBrazilandVenezuela.

Brazil, August-November 2006Brazilinterruptedindigenousmeaslestransmissionin2000.Between2001and2004,only4measlescaseswere reported, all imported from Europe and Japan. In 2005, a six-case outbreak occurred following animportationfromtheMaldivesIslands.[2]

InNovember2006,BahíaStatereportedameaslesoutbreakof55confirmedcases.ThefirstcaseshadrashonsetinlateAugust(EpidemiologicalWeek/EW35)andthelastcaseoccurredinEW49,2006(Figure1).Casesoccurred infive ruralmunicipalities: JoãoDourado(18cases),Filadélfia (33), Irecê (1),SenhordoBonfim(2),andPindobaçu(1).JoãoDouradoandIrecêarecontiguousmunicipalities,asareFiladélfiaandSenhordoBonfim.JoãoDouradoandFiladélfiaaccountedfor93%ofthecases.Themajorityofcasesweremen:55%inJoãoDouradoand79%inFiladélfia.Theageofthecasesrangedfrom7monthsto37years(Figure2).Noneofthecaseshadahistoryofbeingvaccinated.Sevencaseswerehospitalized.Nodeathswerereported.ThemeaslesgenotypeidentifiedinJoãoDouradowasD4,geneticallyrelatedtothemeaslesvirusthatwasimportedtoCanadain2006.D4hasbeenisolatedinEurope,Africa,andAsia.

TheoutbreaksinJoãoDourado/IrecêandFiladélfia/SenhordoBonfimtookplacesimultaneously.CasesinFiladélfia/SenhordoBonfimwereidentifiedandreportedlate.InJoãoDourado/Irecê,casesoccurredamong

Figure 1. Confirmed Measles Cases by Epidemiological Week of Rash Onset, Municipalities of Bahía State, Brazil, 2006

Source:MinistryofHealth,Brazil.Dataasof13February2007.

35 36 37 38 39 40 41 42 43 44 45 46 47 48 49Epidemiological Weeks

0

2

4

6

8

Num

ber

of C

ases

Filadélfia

João Dourado

Senhor do Bonfim

Irecê

Pindobaçu

N = 55

2 IMMUNIZATION NEWSLETTER Volume XXIX, Number 1 February 2007 PAN AMERICAN HEALTH ORGANIZATION

persons living on the same street. Most caseswereamongpersonsaged<15years(Figure2).Incontrast,inFiladélfia/SenhordoBonfim,mostcasesweremenaged>15years.Thesourceofthevirusand theepidemiological linkbetweencases in João Dourado/Irecê and Filadélfia/SenhordoBonfimhavenotyetbeenidentified.TheaffectedareasinBahíaareheavilytraveleddue to the extensive trading of agriculturalproductsandmigrationofagriculturalandmineworkers.

Allsuspectcaseswereinvestigatedbyhomevis-its, exhaustive contact follow-up, and collectionofbloodforserologytestingandnasopharyngealspecimensforvirusisolation.Difficultiesinensur-ingtimelyspecimencollectionandlaboratorykitstock-outsresultedindelayedlaboratoryconfir-mationofsomeofthecasesandtheinabilitytoisolatethevirusfromFiladélfia.Extensivevacci-nationwastargetedtoreachsusceptiblepersonslivingintheoutbreaklocale.Routinevaccinationwas strengthened. Active case-searches wereconducted inhealthcarefacilitiesandthecom-munity,includingschools,businesses,andcom-mercial areas. Approximately 30,000 personswerevaccinated. Ameaslesalertand technicalinformationweredisseminatednationwide.

Duetotheincreasedvaccinedemandfollowingthis outbreak and rubella outbreaks in MinasGeraisandRiodeJaneiro,Brazilhaspurchased1millionmeasles-mumps-rubella(MMR)vaccinedosesand4.2millionmeasles-rubella(MR)vac-cinedosesthroughPAHO’sRevolvingFund.ThecountryhasrequestedanadditionalfivemillionMRandMMRvaccinedosesfromtheRevolvingFund, as it is planning to conduct measles/ru-

bellavaccinationactivitiesinsusceptiblegroupsin2007.

Venezuela, November 2006 – Febru-ary 2007FromFebruarytoJune2006,Venezuelareportedameaslesoutbreakof81confirmedcases(45inthe capital city Caracas, 29 in Carabobo State,4 inNuevaEspartaState, and3 inZulia State)(Figure 3). The index case-patient traveled toSpainduring theperiodofexposure.Thevirusisolated from this outbreak was B3, the samegenotypecirculatinginSpain.Venezuelahadnotreportedcasessince2002.[3]

After epidemiological silence, Venezuela re-portedanotherclusterof12confirmedcasesinNovember2006.AllcaseswereresidentsoftheCamaguánmunicipalityinGuáricoState.Geno-typingispending.

In December 2006, the country reportedanothermeaslesoutbreak inPuertoAyacucho,in Amazonas State. A total of 25 cases wereconfirmed. The rash onset of the last casewason15February2007.Twentythreeoftheconfirmed cases are children aged <5 years;14 cases are infants aged <1 year. Coveragelevels inAmazonasStatehavehistoricallybeenlow. Active measles case searches are beingconducted in Puerto Ayacucho and will beextended to the rest of the country.Of all 118confirmedcases reportedsinceFebruary2006,only4hadahistoryofbeingvaccinated.

ConclusionBest practices for outbreak response includeintensifyingepidemiologicalsurveillance,qualitycaseinvestigation,andfollow-upofcontacts.

Vaccinationactivities aim to get aheadof virustransmission. They should target contacts andpersonsinplacesofpossibletransmissionand/or possible exposure, and in places commonlyfrequentedbythecase.

References:1. Pan American Health Organization. Measles Virus Im-

portations:AConstantThreat. Immunization Newsletter2006;28(3).

2. deBarrosFR,Danovaro-HollidayMC,ToscanoC,SegattoTC,VicariA,LunaE.Measlestransmissionduringcommer-cialairtravelinBrazil.JClinVirol.2006Jul;36(3):235-6.

3. PanAmericanHealthOrganization.MeaslesOutbreakinVenezuela. Immunization Newsletter2006;28(2).

Figure 2. Confirmed Measles Cases by Age Group, Municipalities of Bahía State, Brazil, 2006

*Datafor7casesnotshown.Source:MinistryofHealth,Brazil.Dataasof13February2007.

0

2

4

6

8

10

12

14

16

<1 year 1-4 years 5-14 years 15-29 years >30 yearsAge Groups

Num

ber o

f Cas

es

FiladélfiaJoão DouradoSenhor do BonfimIrecê Pindobaçu

N = 48*

Figure 3. Geographic Distribution of Confirmed Measles Cases, Venezuela, 2006-2007

Source:MinistryofHealth,Venezuela.

1 dot = 1 case

February–June 2006

November–December 2006

December 2006–February 2007

Nueva Esparta:4 cases

Zulia:3 cases

Carabobo:29 cases

Guárico(Camaguán):

12 cases

Metropolitan District of Caracas (Miranda and Capital District):

45 cases

Amazonas(Puerto Ayacucho and rural areas):

25 cases

PAN AMERICAN HEALTH ORGANIZATION IMMUNIZATION NEWSLETTER Volume XXIX, Number 1 February 2007 �

bean,Canada,andtheUnitedStates.Asof2006,influenzavaccinationhasbeenintroducedinthepublicsectorin30(67%)ofthe45countriesorterritories.Nineofthe30countrieshaveintro-ducedthevaccinein2006.Anotherfourcoun-tries are planning introduction in 2007 (Figure1).Twocountries(HaitiandPeru)areplanningintroductionin2008.Onlyninecountriesorter-ritories(22%)donothaveimmediateplansforvaccinationintroductioninthepublicsector.

The formulationusedand the timeof theyearwhenthevaccineisadministeredvarywiththecountry’s geographical location. Fifteen of the30 countries (50%) that have introduced influ-enza vaccination in the public sector are plan-ningtoextendvaccinationintoadditionalcover-age groups or add influenza vaccine into theirimmunizationschedules.Thetargetgroupsvaryamong countries; however,most countries tar-gettheveryyoungandtheelderly.Tencountriesor territories of those with public vaccination(33%)currentlyimmunizeorplantoimmunizepopulations in close contact with birds. Brazilhas also included the vaccination of additionalat-risk groups, including indigenous and in-carcerated populations. Twenty-seven (90%)countriesvaccinatetheirhealthworkersagainstinfluenza.AmongthecountriessurveyedunderPAHO’squestionnaire(39),33(85%)havesen-tinelsitesurveillancesystemsforinfluenza.Mostcountriesorterritoriesshowanimprovementinsurveillancesincethelastsurveywasconducted(2004).However,thegapstillremainsforlackofinformationintropicalareas.

Countriespurchaseinfluenzavaccinesfromdif-ferent suppliers. In 2006, 22 (73%) countries

INFLUENZAfrom page 1 Figure 1. Introduction of Seasonal Influenza Vaccine in Latin America and the Caribbean, 1970-2007

Source: EPIManagersSurvey2004-2006;WHOInfluenzaSurvey2006.FrenchGuiananotincluded.

Jamaica

Turks & Caicos

Dominican Republic

Antigua & Barbuda

St. Lucia

Trinidad & Tobago

BarbadosGrenada

Suriname

Venezuela

Guatemala

Nicaragua

Ecuador

Introduced in 1970-2003.

Introduced in 2004-2006.

To be introduced in 2007.

Anguilla

The Bahamas

Paraguay

Colombia

Mexico

El Salvador

Costa Rica

Panama

withpublic influenzavaccinationpurchased in-fluenza vaccines through the PAHO RevolvingFund.Thereisahighdemandforinfluenzavac-cineascountriesintroduceitintheirimmuniza-tionschedules,andavaccineshortage,especial-lyforcountriesusingtheNorthernHemisphereformulation, has been experienced. Brazil andMexicohavetechnologytransferagreementstoproduceinfluenzavaccineintheRegion.

Prior to2004, influenzavaccinationhasgradu-allybeenintroducedintheRegion.Since2004,its introduction has been accelerated dramati-cally,assupportedbyPAHO’s2004TAGrecom-mendations. It will be important to continue

establishingpublicpoliciesforvaccineintroduc-tioninthepublicsectortoreducemorbidityandmortality due to influenza in high-risk groups.Hopefully,thedemandincreasewillgenerateasurgeinvaccineproduction.Highqualitysurveil-lance iscritical fordeterminingtheformulationandpropertimeforadministeringthevaccineineachsub-region,especiallytropicalareaswheremoreinformationisneededtounderstandpat-terns of viral transmission. PAHO is currentlyworkingwiththeU.S.Centers forDiseaseCon-trolandPreventiontostrengthensurveillanceinLatinAmerica.

Pneumonia Hospitalization in Children in Uruguay and Influenza and Pneumococcal VaccinationBackgroundImmunization is one of the most effective in-terventions to fight child mortality. Yet, missedvaccination opportunities continue to occur inchildrenandlife-savingvaccinesarestillunder-utilized.Thisarticlepresentsdataonpneumo-nia cases in children inUruguayanddiscussescurrentimmunizationrecommendations.

MethodologyWithsupportfromthePanAmericanHealthOr-ganization,apopulation-basedpneumoniastudy

wasconductedinUruguayamongchildrenaged0-14yearshospitalizedinpublichospitalsintheWestern Departments of Paysandú and Salto,andthenationalreferencehospitalforchildrenin Montevideo during the period June 2001 toMay2004.[1]Atotalof5,346pneumoniahospi-talizationswereanalyzed.

ResultsOfthe2,651childrenaged0-14yearshospitalizedin Paysandú and Salto, 40.5% were aged 6-23months. In Paysandú and Salto, 32.6% of the

patientsaged>23monthshadco-morbidityand38.2%hadbeenpreviouslyhospitalized.

In Montevideo’s national reference hospital,1,489childrenaged>23monthswerehospital-ized. Streptococcus pneumoniae was isolatedfromthebloodorpleuralfluidof259ofthem.

DiscussionSince2004,Uruguayhasofferedfree influenzavaccination for children aged 6-23 months (inaddition to vaccinating older adults). However,coverage rates were not adequate during thefirstyear(15%),andevenlessduringthesecondyear, when 127,494 fewer vaccine doses wereadministered.[2] In the study, children aged 6-23 months represented the highest proportionofchildrenhospitalizedduetopneumonia.Since

� IMMUNIZATION NEWSLETTER Volume XXIX, Number 1 February 2007 PAN AMERICAN HEALTH ORGANIZATION

thisagegroupwaseligibleforinfluenzavaccine,a proportion of those pneumonia cases mighthave been avoided with influenza vaccination.Childvaccination(2doses)shouldbecompletedbeforetheinfluenzaseason.InUruguay,circula-tionbeginsat theendofAprilorbeginningofMay,accordingtodatafromtheNationalRefer-enceCenterforInfluenza.

Uruguay has not yet introduced a conjugatedpneumococcalvaccine.However,theexistent23-valentpolysaccharidevaccinecanbeofferedtopersonsaged>2yearsatrisk.Thankstotwelveyearsofinvasivepneumococcaldiseasesurveil-lance,Uruguayhasdocumentedtheabsenceofsignificant changes in the most prevalent inva-siveserotypescirculatinginchildrenandadults,supporting the relevanceof thepolysaccharidevaccine’sformulation.[3]Thehighproportionofchildrenwithco-morbiditieswhowerehospital-ized during the study period reemphasizes theimportance to considerpneumococcal vaccina-tioninthishigh-riskgroupinUruguay.

Editorial NotePneumococcus pneumonia and influenza areamongthemaincausesofhospitalizationsanddeathsinchildrenworldwide.Itisestimatedthatpneumococcal disease causes around 1.6 mil-lionsdeathsperyear,ofwhich800,000occurinchildrenaged<5years.Regardinginfluenza,lit-eraturefromtheUnitedStatesindicatesthat30%ofchildrenareinfectedeachyearwithinfluenzaviruses.Diseasedurationandviralexcretionaremore prolonged in children, which contributestochildrenbeingthemainsourceofvirustrans-missioninthecommunity.[4]Theaverageexcesshospitalizationassociatedwithinfluenzarangesfrom40per100,000inschool-agedchildrento1,000 per 100,000 in infants aged <6 months.Furthermore,influenzainfectioncanleadtose-verepneumococcalpneumonia.[5]

Themostcommonlyusedinfluenzavaccineisatrivalent, inactivated influenzavaccine, contain-ing the two A subtypes H3N2 and H1N1 and

one type B virus. Influenza vaccine should notbegiventochildrenaged<6months,andchil-drenaged6–36monthsshouldreceivehalftheadult vaccine dose. To provide protection, twoinjectionsgivenatleastonemonthapart,shouldbeadministeredtochildrenaged<9yearswhohaveneverreceivedthevaccinebefore.Vaccina-tionisrecommendedannually,asthevaccineisreformulatedeachyearaccordingtodataoncir-culating influenzastrains.Themainpurposeofseasonalinfluenzavaccinationistoavoidsevereinfluenzaanditscomplications.

PAHO’s Technical Advisory Group on Vaccine-preventableDiseases (TAG) recommends influ-enzavaccinationforchildrenaged6-23months,in addition to vaccinating health care workers,chronicallyillindividuals,andelderlyadults.[6]Bytheendof2006,vaccinatingchildrenaged6-23monthshadbeenrecommendedby13coun-tries/territoriesintheAmericas.Threeadditionalcountries were vaccinating children aged <5yearswithhighriskconditions.However,wheremonitored,coveragelevelsaresignificantlylow-erthanforotherroutinechildhoodvaccines.

Polysaccharide-protein conjugate pneumococ-cal vaccines are effective in children aged <2years, when the rates of pneumococcal inva-sivediseasearehigher.DatafromtheRegionalPAHO/SIREVAsurveillancenetworkindicatethatserotype14ismostoftenisolatedinthemajor-ity of countries. The existing 7-valent vaccinewouldcover65%ofserotypes,a9-valent77%,and an 11-valent 83%. Conjugate pneumococ-calvaccinescanbeeasilyintegratedintoroutineimmunizationschedules.Routine immunizationwiththesevaccinesshouldbeinitiatedbefore6monthsofageandmaystartasearlyas6weeksof age. Conjugate pneumococcal vaccines maybeadministeredat the same time, althoughata different anatomical site, with other vaccinesintheinfantimmunizationprograms(DTP,Hib,HepatitisB,polio).Thehighcostsofconjugatedpneumococcalvaccines, togetherwiththescar-cityoflocaldataregardingcirculatingserotypes,have limited the introductionof these vaccines

in the Americas. The 23-valent polysaccharidepneumococcal vaccine can be administeredanytimeoftheyear,topersonsaged>2years.It containspurifiedcapsularpolysaccharidesoftwenty-threeofthemostcommonpneumococ-cusserotypes.Vaccinationisusuallyprescribedto persons with risk factors for pneumococcaldisease and those aged 65 years or older. Re-vaccinationafterfiveyearsisonlyindicatedforthosepersonsathighrisk.

WHOconsiderspneumococcalconjugatevaccinetobeapriorityforinclusioninnationalimmuni-zation programs and encourages countries toconductsurveillanceforpneumococcalinvasivedisease.In2006,TAGrecommendationsfocusedon strengthening standardized pneumococcalsurveillancethroughouttheRegionoftheAmeri-cas. [6]Pneumoniaandmeningitis surveillanceinchildrenaged<5yearswillallowassessingtheburdenofdiseaseanditsprofileinthepopula-tion, and evaluating the impact of vaccinationoncethevaccineisintroducedinacountry.

Contributed by:Dr.MaríaHortalandDr.InésIraola.Nation-alChildHealthProgram,MinistryofPublicHealth,Uruguay.

References:1. HortalM,EstevanM,IraolaI,DeMucioB.Apopulation-

basedassessmentofthediseaseburdenofconsolidatedpneumonia in hospitalized children under five years ofage.IntJInfectDis.2006Sep22;[Epubaheadofprint]

2. DeMucioB,IraolaI,LauraniH,GoñiN,HortalM.Primeraexperiencianacionaldevacunaciónanti-influenzaenpo-blacióninfantil.2006;77:13-17.

3. CamouT,PalacioR,DiFabioJL,HortalM.Invasivepneu-mococcal diseases in Uruguayan children: comparisonbetweenserotypedistributionandconjugatevaccinefor-mulations.Vaccine.200316;21(17-18):2093-6.

4. Heikkinen T. Influenza in children. Acta Paediatr. 2006;95(7):778-84.Review.

5. O’BrienKL,WaltersMI,SellmanJ,QuinliskP,RegneryH,SchwartzB,DowellSF.Severepneumococcalpneumoniainpreviouslyhealthychildren:theroleofprecedinginflu-enzainfection.ClinInfectDis.2000;30(5):784-9.

6. Pan American Health Organization. Technical AdvisoryGroup on Vaccine-preventable Diseases. Final report.2006.

VWA and World Cricket Cup Unit Efforts to Prevent DiseasesThe2007VWAwilltakeplaceduringtheclosingweekofthe2007CricketWorldCup(CWC),andPAHOinvitesvisitorstocelebrateVWA’sclosingduringthelastCWCmatchon28April.CWCwillbeheldinnineCaribbeancountriesandterritories,startinginMarch.PAHOacknowledgesthesignificanceofthiseventfororganizingandparticipatingcountriesasmanyplayersandfansfromotherRegionswillbetravelingtotheCaribbean,fuelingtheriskfordiseaseimportation.Therefore,aspartoftheVWA,theorganizationfullysupportstheeffortsofCaribbeancountries,priorandduringCWC,topreventsuchimportationsbyraisingawarenessofdiseasepreventionandsurveillance.Activitieswillincludeincreasedepidemiologicalsurveillancebefore,during,andafterCWC,andintensificationofimmunizationeffortsinhigh-riskandvulnerablepopulations.

Illustration:BolaOyeleye/PAHO

PAN AMERICAN HEALTH ORGANIZATION IMMUNIZATION NEWSLETTER Volume XXIX, Number 1 February 2007 �

Vaccination Week in the Americas: Fifth AnniversaryThe 2007 Vaccination Week in the Americas(VWA) will take place on 21-28 April. Thisyear, countries of the Region of the Americawill celebrate the fifth anniversary of VWA, aninitiative endorsed by all member countries ofthe Pan American Health Organization (PAHO)in2003.Since2003,VWAhasreachedatotalofabout147millionchildren,women,men,and older adults, focusing on hard-to-reach populations, isolated bordercommunities, and other areas withlowimmunizationcoverage.

As the Americas prepare for thisyear’scampaign,thestatusofim-munization in the Region’s haschanged considerably over thelastfiveyears.Rubellaisonthebrink of elimination, and newvaccines are being introduced– suchas thoseagainst rotavirus,pneumococcus, and human papil-lomavirus. Yet, inequitiesarestillareality,andtheAmericasfacethechal-lenge of reaching all those left behind.The2007VWAwillthereforemaintaintheprinciplesofequity,access,andPanAmerican-ism.Thisyear’sobjectivesareasfollows:

• Increaseandstrengthenroutineimmunizationcoverage;

• Improvecoverageinisolatedandvulnerablepopulations;

• Continue to promote basic health carethroughintegratedactivities;

• Maintainimmunizationonthepoliticalagen-dasofMemberStatesandengagethemina

celebrationofhealththathighlightssolidar-ity;

• Improvetheawarenessofthegeneralpopu-lationaboutdiseasesandvaccines,includingnewvaccinesonthemarket;and

• Focuson the riskof importationof vaccine-preventablediseasessuchasmeasles,rubella,andpolio.

In addition to the technical cooperationprovided by PAHO’s Immunization Unit, socialcommunication support has been crucial forthesuccessofVWAinpreviousyears.PAHO’sPublicInformationOfficehasdesignedaspeciallogo and posters celebrating the VWA’s fifth

anniversary. They will be accessible soonfrom a webpage dedicated to VWA

activities around the Region.1 Publicservice and radio announcements arebeing produced, with a special focuson Caribbean countries and prioritycountriesintheAmericas.

BuildingontheexampleoftheAmer-icas,theEuropeancountrieswillbeconducting their first ImmunizationWeek inAprilalso,aweekprior toVWA. Inviewof theotherRegions’

growing interest in sustaining immu-nizationachievements,improvingcov-

erage in underserved populations, andmaintainingimmunizationonthepolitical

agenda,VaccinationWeekmight somedaybecomeaglobalinitiative.

1www.paho.org/English/DD/PIN/vw_2007.htm

PAHO Revolving Fund Vaccine and Syringe Prices for 2007Table 1 shows 2007 prices for vaccines beingoffered through the PAHO Revolving Fund forVaccine Purchases. In summary, the weightedaverage of price increase for 2007 comparedto 2006 was 2.5%. In some cases the averagevaccinepricehasdecreased,suchasforhepatitisB pediatric (-9%) and Pentavalent (-2%). ThiswasfacilitatedbynewsupplysourcesandmoreefficientworkingrelationshipsbetweenMemberStates, PAHO, and the suppliers to managechanges indemandforecastingandproductionprocessesduring2006.Priceincreases,however,

alsooccurredin2007,mostnotablyforDPT10(+32%),influenza(11%)andMMR(+8%),asaconsequenceof limitedsupply, lowaccuracyindemandforecasting,andmarketbehavior.

Overall the number of vaccine presentationscontinuestogrowin2007withtheinclusionofliquidPentavalentandOPVglass.NotshowninTable1isinfluenzaNorthernHemisphere,bothadultandpediatric.Itisanticipatedthatsupplierswill be in a better position to comply withPAHO’srequirementsforpediatricpresentationof seasonal influenza vaccine later this year.

Also, the initial supply of rotavirus is expectedto be available in June 2007 following WHOprequalificationinJanuary2007.

In anticipation of possible supply shortages in2007forMMR,polio,influenza,andPentavalent,the Revolving Fund will continue to strengthenits working relationships with countries andsuppliers to manage modifications of demandandsupplyandensureasmoothandconstantflowofvaccinesandavoidstockouts.

Finally,2007pricesforsyringesareavailableatthefollowinglink:https://intranet.paho.org/AM/PRO/PRO.asp.Itisimportanttomentionthat,in2006,PAHOinitiatedaqualitycontrolsystemforsyringesbasedonISOstandardsandintendedtoguaranteethequalityandsafetyofsyringes.

� IMMUNIZATION NEWSLETTER Volume XXIX, Number 1 February 2007 PAN AMERICAN HEALTH ORGANIZATION

See RUBELLApage 8

Rubella Elimination in the Americas:Last Countries to Conduct Vaccination Campaigns

The Region has demonstrated remarkableprogress in the implementation of strategiesfor the effective interruption of endemicrubella transmissionthroughthevaccinationofadolescent and adult populations. In 2007, sixcountrieswill finalizehigh-qualitymass rubellaelimination campaigns: Cuba, Bolivia (2ndstage),Guatemala,Haiti,Mexico(2ndstage),andVenezuela (2nd stage). In addition, El SalvadorandUruguaywillconduct follow-upcampaignstodecreasesusceptiblepopulations tomeaslesand rubella in their respective countries (see

Table1onpage8).

Highqualitycampaignsareacritical.Importantfactorstoconsiderinclude:

1. The age group to be vaccinated should bedetermined based on the epidemiology ofrubella in thecountry,anassessmentof thesusceptible population, the year of vaccineintroduction, subsequent rubella vaccinationcampaigns, and theneed toprotectwomenofchildbearingage.

2. Socialcommunicationshouldbeemphasizedduringcampaignplanning.

3. Quality campaigns require vaccinating bothfemale and male populations, includingsusceptible adults, and reaching coveragelevels close to 100% of the targetedpopulation.

4. The highest political commitment andparticipationshouldbeensured.

5. Fullparticipationofthepopulation,scientificsocieties, social sectors, and media requiresintensivesocialmobilizationeffortsandlocalmicro-planningactivities.

6. Informationsystemsshouldbepracticalanduseful.

7. The capacity should exist to detect andrapidlyrespondtosafetyconcernsandotheremergingissuesduringcampaigns.

Vaccine DosesperVialAverage

Cost

BCG 10 $0.1036

DPT 10 $0.1580

dT(Adult) 10 $0.0750

DT(Pediatric) 10 $0.0891

DTaPTripleAcellular 1 $8.1250

DPT-Hib1 $3.4000

10 $3.1500

DPT-HepatitisB-HibLyophilized 1 $3.9200

Liquid 1 $3.9500

HibLyophilized 1 $3.1500

Liquid 1 $3.2500

HepatitisBRecombinantPediatric 1 $0.2343

HepatitisBRecombinantAdult1 $0.4270

10 $0.2300

Measles/Rubella 10 $0.4688

Measles/Mumps(LeningradStrain)/Rubella1 $1.5000

10 $0.9000

Measles/Mumps(UrabeStrain)/Rubella1 $2.5000

10 $1.4000

PolioGlass 10 $0.1600

Plastic 10 $0.1700

Vaccine DosesperVialAverage

Cost

PolioGlass 20 $0.1478

Plastic 20 $0.1500

Polio(Plastic) 25 $0.1550

PolioInactivated(withsyringe) 1 $3.3000

RabiesVaccineHumanUse/InactivatedPurifiedCellCulture

FrenchOrigin 1 $10.5000

GermanOrigin 1 $11.5000

TT 10 $0.0645

YellowFever 5 $0.6500

InfluenzaAdultSouthernHemisphere

withprefilledsyringe 1 $3.6500

withsyringe 1 $3.6500

InfluenzaAdultSouthernHemisphere 10 $2.6600

InfluenzaPediatricSouthernHemisphere(withsyringe)

1 $3.2000

InfluenzaPediatricSouthernHemisphere 20 $1.3300

23-Valentpolysaccharidepneumococcal(withsyringe)

1 $9.2000

HepatitisAPediatric

withpre-filledsyringe 1 $7.9500

withsyringe 1 $7.6000

HepatitisAPediatric 1 $7.9500

Varicella 1 $10.4000

MeningococcalA+C 1 $2.2750

Table 1. Prices for Vaccines Purchased Through the PAHO Revolving Fund, 2007 (Prices shown in U.S. Dollars)

PAN AMERICAN HEALTH ORGANIZATION IMMUNIZATION NEWSLETTER Volume XXIX, Number 1 February 2007 7

Annual Summary of AFP and Measles/Rubella Indicators, 2006*Acute Flaccid Paralysis (AFP) Surveillance Indicators (Period Between Epidemiological Weeks 01 to 52, 2006)

Country NumberofCasesAFPRateper100,000<15

YearsOld%CasesInvestigated

<48hours%with1SampleTakenWithin14DaysofOnset

%SitesReporting

Argentina 143 1.40 87 78 74Bolivia 40 1.10 95 78 52Brazil 369 0.68 97 72 90Canada 30 0.53 … … …CAREC 17 0.84 96 57 100Chile 76 1.77 83 84 96Colombia 220 1.73 57 81 91CostaRica 7 0.57 86 29 …Cuba 25 1.15 100 96 100DominicanRepublic 17 0.54 59 94 82Ecuador 32 0.75 97 75 73ElSalvador 79 3.38 95 87 90Guatemala 97 2.13 91 74 …Haiti 15 0.37 93 27 73Honduras 76 2.57 96 93 93Mexico 447 1.42 98 81 96Nicaragua 27 1.26 100 93 100Panama 9 0.92 78 78 93Paraguay 14 0.70 93 86 92Peru 77 0.91 92 60 100Uruguay 8 0.98 100 88 75USA … … … … …Venezuela 68 0.82 94 85 85

Total* 1893 1.10 90 78 89

…Notreporting *ExcludingCanadaandUSA

Measles/Rubella Surveillance Indicators (Period Between Epidemiological Weeks 01 to 52, 2006)

Country%Sites

ReportingWeekly%CaseswithAdequate

Investigation%CasesWithAdequate

Sample%Lab.Received

<5Days%Lab.Result

<4Days%CasesDiscarded

byLab.Argentina 85 11 92 74 82 99Bolivia 52 96 99 82 77 99Brazil 86 75a 77 44 82 97Canada ... ... ... ... ... ...CAREC 99 81 97 28 91 99Chile 96 26 91 79 93 97Colombia 92 60 96 79 84 97CostaRica ... ... ... ... ... ...Cuba 95 96a 100 65 100 96DominicanRepublic 81 72 98 59 64 97Ecuador 67 60 99 87 81 99ElSalvador 88 80 99 96 93 99FrenchGuiana ... ... ... ... ... ...Guadeloupe ... ... ... ... ... ...Guatemala 49 91 96 77 92 98Haiti 73 88 83 21 32 90Honduras 94 94 98 81 89 97Martinique ... ... ... ... ... ...Mexico 92 99 97 89 76 99Nicaragua 100 82 99 57 94 99Panama 93 73 99 68 95 97Paraguay 92 70 99 87 100 100Peru 98 81 88 74 54 89PuertoRico ... ... ... ... ... ...Uruguay 59 20 80 100 44 100USA ... ... ... ... ... ...Venezuela 72 87 98 66 79 99

Total/Average 86 78 85 59 80 97

aAlsoincludesinformationonactivecase-searches. …Notreporting

Source:PESS,MESS,andcountryreportstoImmunizationUnit,PAHO. *Dataasof28February2007.

� IMMUNIZATION NEWSLETTER Volume XXIX, Number 1 February 2007 PAN AMERICAN HEALTH ORGANIZATION

The Immunization Newsletterispublishedeverytwomonths,inEnglish,Spanish,andFrenchbytheImmunizationUnitofthePanAmericanHealthOrganization(PAHO),RegionalOfficefortheAmericasoftheWorldHealthOrganization(WHO).ThepurposeoftheImmunization NewsletteristofacilitatetheexchangeofideasandinformationconcerningimmunizationprogramsintheRegion,inordertopromotegreaterknowledgeoftheproblemsfacedandpossiblesolutionstothoseproblems.

ReferencestocommercialproductsandthepublicationofsignedarticlesinthisNewsletterdonotconstituteendorsementbyPAHO/WHO,nordotheynecessarilyrepresentthepolicyoftheOrganization.

ISSN1814-6244

VolumeXXVIX,Number1•February2007

Editor:JonAndrusAssociateEditors:BéatriceCarpanoandCarolinaDanovaro

Immunization Unit525Twenty-thirdStreet,N.W.Washington,D.C.20037U.S.A.http://www.paho.org/immunization

Table 1. Countries of the Region of the Americas Conducting Rubella Vaccination Campaigns in 2007

Country Target Population Age Group Date of Implementation Comments

Cuba*2.1million

menandwomen12-24years

February-May2007

Vaccinationisbasedonasusceptibilitystudyandresponsetoamumpsoutbreak.

Guatemala7.8million

menandwomen9-39years 13April2007

Anallianceofpartnershasmobilizedresourcesforcampaignefforts.

Haiti4.7million

menandwomen1-19years October2007

TheMMRvaccinewillbeintroducedintheregularprogramforchildrenaged1year.

Bolivia(2nd stage)

3.5millionchildren

1-15years September2007Afollow-upcampaignisincludedtostrengthenmeaslesandrubellaeliminationefforts.

Venezuela (2nd stage)

9.6millionmenandwomen

18-39years October2007 Thesecondstagewillfinalizerubellaandmeasleselimination.

Mexico**(2nd stage)

20.3millionmenandwomen

17-29years November2007Rubellavaccinationwillbeimplementedthroughouttheremaining34states.

El Salvador800,000children

1-4years June2007Afollow-upcampaignisincludedtostrengthenrubellaandmeasleselimination.

Uruguay200,000children

1-4yearsandsusceptible

populationOctober2007

Afollow-upcampaignisincludedtostrengthenrubellaandmeasleselimination.Acampaigninadolescentandadultpopulationswilldependonsusceptiblecohorts.

*UsesMMRvaccine.**Tobeconfirmed

Note: Argentina,Brazil,andChilearedeterminingsusceptibleadolescentandadultcohortstocompletetheircampaignfortheeliminationofrubellaandcongenitalrubellasyndromeandthestrengtheningofmeasleselimination.

Source:ImmunizationUnit,PAHO.

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