The mobile nature of the population of Khayelitsha makes it imperative that opportunities for immunisation of children are exploited at every visit to health services. Previous studies have demonstrated a high incidence of missed opportunities for immunisation at curative health services. The occurrence of undetected opportunities for immunisation are compared at two prim.ary care institutions: one in which curative and preventive services are provided separately, and one in which these functions are integrated. Far fewer opportunities for immunisation were missed at the integrated service, underscoring the urgency of integrating child health services throughout the country

Barron, Peter

Glass, Belinda

Harrison, David

Sonday, Shahim

v.d. Heyde, Yolande

English

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_-------------------------------'- 575We thank 4th-year medical students, Matthew Youngand Ola Rzepecka, and Nyameka January who conductedrhe Red Cross Hospital componenr of rhe study; Dr PeterBarron of rhe Western Cape Regional Services Council, DrShamed Hassim of CPA Western Cape Region, and DrGilbert Lawrence, Medical Superintendenr, Red CrossHospital, for permission to underrake rhis study; Dr GeorgeSwingler for his assistance; and rhe doctors and professionalnursing sraff in Khayelitsha and A9 rehydration unit forrheir participation.REFERENCESI. Rip M, Woods D, Keen C, de Greot HvC. Perinatal health in theperi-urban township of Khayelitsha, Cape Town. S .4ft Med J1988; 74: 633-634.2. Lachman P, Stander I. Patterns of referral to Red Cross WarMemorial Children's Hospital. S Aft Med J 1990; 78: 404-408.3. Honon S, Claquin P. Cost-effectiveness and user characteristics ofclinic based services for the treatment of diarrhoea: a case study inBangladesh. Soc Sci Med 1983; 17: 721-729.4. Oberle M, Merson M, Islam M, Rahman A, Huber D, Curl in G.Diarrhoeal disease in Bangladesh: epidemiology, monality avenedand costs at a rural treatment centre. lm J Epidemiol 1980; 9: 341.Far fewer missed opportunities for inununisation in anintegrated child health serviceDAVID HARRISON, PETER BARRON, BELINDA GLASS, SHAHIM SONDAY,YOLANDE v. d. HEYDEAbstract The m.obile nature of the population of Khaye-litsha m.akes it im.perative that opportunities forim.m.unisation of children are exploited at everyvisit to he'a1th services. Previous studies havedemonstrated a high incidence of missed opportu-nities for immunisation at curative health ser-vices.The occurrence of undetected opportunities forim.m.unisation are compared at two prim.ary careinstitutions: one in which curative and preventiveservices are provided separately, and one in whichthese functions are integrated. Far fewer opportu-nities for immunisation were missed at theintegrated service, underscoring the urgency ofintegrating child health services throughout thecountry.5 AirMed J 1993; 83: 575·576.TIe policy of the World Health Organisation'sExpanded Programme on Immurlisation (EPI) isthat immunisations should be made available toevery child at every comact with the health care sys-tern. l ,2 But studies in developing countries demonstratethat a significant number of children leave health facili-ties without their incomplete irnmurlisation having beendetected.',4 Opportunities for immunisation are mostlikely to be missed in visits to curative health services."·Fragmented health services undermine efforts toachieve maximum vaccination coverage, particularlyin the face of a rapidly urbanising population. 7 Highmobility of people, far walking distances and long wait-ing times at health services dictate that every opportU-nity for vaccination be exploited.Surveys conducted irl Khayelitsha demonstrate a sig-Centre for Epide:miological Research in Southern Africa, SouthAfrican Medical Research Council, Parowvallei, CP, and ChildHealth Unit, Dept of Paediatrics and Child Health, Universityof Cape Town .DAVID HARRISON, M.B. CH.B.Western Cape Regional Services Council, Cape TownPETER BARRON, B.COM., FF.C.H. (S.A.)Department OfCOIllIllunity Health, University of Cape TownBEU}..TJ)A GLASS, 4th-year medical studentSHAHIM SONDAY, 4rh-year medical srudentYOLA}..TJ)E v. d. HEYDE, 4th-year medical studentAccepted 24 Mar 1993.nificant improvement in proven vaccination coverage ofchildren following mass measles immunisation cam-paigns.s" These improvements, however, are not sus-tained, and coverage ourside of campaign periods wasfound to be roughly 60 -70%.'0The key to better vaccination coverage lies inchanges to routine health services."A study of curative facilities in the western Cape con-ducted in January 1990 found that a considerable num-ber of opportunities to immunise children againstmeasles were being missed. 11 It concluded that there wasa need for rapid integration of preventive and curativecomponents of health care into a metropolitan-basedprimary health care service.An integrated service for preschool children wasintroduced at the Nolungile Primary Health Care(PHC) Centre in Site C, Khayelitsha, in January 1992.Previously, children who were ill were treated at the dayhospital, while children attending child health clinics orrequiring treatment for tuberculosis were seen at thelocal authority facility - located on the same premisesas the day hospital.The restructured service allows a single portal ofentry for all children less than 6 years of age, regardlessof their reason for attendance. All children are initiallyscreened by a nurse aid an'd clerk: weights are plotted onthe Road-to-Health cards (RTHCs), and temperaturesare recorded in the event of illness. Well babies aremainly seen by professional nurses with general training,while sick children are seen by nurses with an additionalqualification in primary care. Children with complicatedor severe illness are referred to a doctor employed by theCape Provincial Administration (CPA), but physicallylocated on the local authority side of the health com-plex.The aim of this study was to compare the detectionof opporturlities for immunisation at the integrated childhealth service at Nolungile PHC Centre with that at asimilar health complex in which preventive and curativecare of children were still provided separately.The objectives were to determine; (i) the frequencywith which RTHCs were requested by health personnel- essential for the detection of incomplete immunisa-tion; and (ii) the number of children whose incompleteimmunisation was not detected during their visit to thehealth facility.A significant reduction in missed opportunities forimmunisation, achieved as part of the routine of an inte-grated facility, is a powerful motivation for rapid integra-tion of all preventive and curative health services forchildren.:.-L _Methods DiscussionResults. No documentation of up-to-date immunisation available.t No documentation of up-to-date immunisation available, or no history of com-plete immunisation given by the carer.TABLE!.Missed opportunities for immunisation at two primarycare institutionsFewer children were seen at Crossroads II than atNolungile Clinic during the course of the week. Dailyattendance at Crossroads fluctuated, because childhealth (preventive) clinics are only held on Tuesdaysand Thursdays. A parent, in fact always the mother,accompanied the child in over 90% of attendances. AtNolungile, the RTHC was requested in 90% of cases.The remaining 10% were children receiving daily tuber-culosis treatment, who bypassed the routine screeningmechanisms. In fact, this group constituted all but 3(91 %) of the missed opportunities for immunisation atNolungile (strict definition). Although 75% of childrenat Crossroads had RTHCs available, health personnelonly requested the card in 42,7% of cases (Table I).According to the strict definition, three times asmany opportunities for immunisation were missed atCrossroads IT as opposed to Nolungile (X' =77,4; df =1; P < 0,001). Four times as many opportunities forimmunisation were missed at Crossroads, according tothe lenient definition (X' =53,4; df=1; P < 0,001).1. World Health Organization. Expanded Programme on Immuniza-tion: missed opportunities for immunization. Wk(y Epidemiol Rec1989; 64: 93-100.2. World Health Organization. EPI: missed opportunities and accepr-ability ofimmunizati<in. Wk(yEpidemiol Rec 1989; 64: 181-188.3. World Health Organization. EPI: missed opportunities for immu-nization (Mozambique). Wkly Epidemiol Rec 1989; 64: 32-34.4. World Health Organization. EPI: programme review (Turkey).Wkly Epidemiol Rec 1988; 63: 185-192.5. World Health Organization. EPI: missed opponunities for immu-nization (Comoros). Wk(y Epidemiol Rec 1988; 63: 344-346.6. World Health Organization. EPI: Global Advisory Group. WklyEpidemiol Rec 1989; 64: 5-12.7. Jacobs ME, Kibel MA. An urban straregy rowards the EPI. S AftMed] 1987; 72: 327-328.8. Kearney M, Yach D, Van Dyk H, Fisher S. Evaluation of a massmeasles immunisation campaign in a rapidly growing peri-urbanarea. SAftMed] 1989; 76: 157-159.9. Berry D, Yach D, Hennink M. An evaluarion of rhe narionalmeasles campaign in the new shanty areas of Khayelirsha. S 'AftMed] 1991; 79: 433-436.10. Coerzee N, Yach D, Blignaut R, Fisher S. Measles vaccinationcoverage and its determinants in a rapidly growing peri-urban area.S Aft Med] 1990; 78: 733-737.11. Barron P, Buch E, Behr G, Crisp N. Mass immunisation cam-paigns - do they solve the problems? S Aft Med] 1987; 72: 321-322 .12. Yach D, Metcalf C, Lachman P, er al. Missed opportunities formeasles immunisation in seleCted western Cape hospitals. S AftMed] 1991; 79: 437-439.An integrated child health service has been shown toexploit opportunities for immunisation far more effec-tively than one in which preventive and curative servicesare rendered separately. Far greater use is made of theRTHC by personnel in the integrated service.However, where a separate vertical programme stillexists in the largely integrated service, namely the man-agement of tuberculosis, opportunities for immunisationare still missed.Besides ensuring that far fewer opportunities forimmunisation are missed, the integrated child healthservice has another important benefit. This is that olderchildren (over the age of 2 years) who have slippedthrough the net and missed their routine primary immu-nisations will be picked up when they attend as sickchildren. This is particularly important in populationswith high mobility, as is the case in most areas of rapidurbanisation. The importance of picking up these olderchildren has been demonstrated at Site C. In 1992, thisclinic immunised ten times as many children in theage category 2 - 5 years as did a comparable clinic inSite B, despite the fact that the total number of childrenimmunised at the two clinics was approximately equal(W. Lombard, Western Cape Regional Services Council- personal communication).The implications of these findings are that:1. The tuberculosis programme should be integratedinto the general child health service. If there are othervalid reasons for retaining tuberculosis as a vertical pro-gramme, staff in the tuberculosis. treatment room in par-ticular should be urged to check RTHCs for incompleteimmunisation as well as for growth monitoring - surelya fundamental part of the routine management of tuber-culosis!2. The remaining health cenrres in which preventiveand curative child health services are separate should beintegrated as soon as possible.There is now a local precedent for integrated childhealth services. The system is operating well - and thisstudy shows that children are already reaping the bene-fits.REFERENCESWe are grateful to Drs Shahied Hassiem and StewartFisher for permission to undertake this study; CarolMetcalf for infonnation concerning the previous missedopportunities study in Khayelitsha; and Pam Morape andNyameka January, our interpreters.17893,042,775,335,425,3Crossroads.Crossroads II Health Centre was chosen as the non-integrated child health service, because it is structurallysimilar to that at Nolungile in Site C, Khayelirsha, withpreventive (Western Cape Regional Services Council)and curative (CPA) services being housed in the samebuilding. The study was conducted over 5 consecutivemornings from 16 to 20 March 1992. InteIViews wereconducted by 4th-year medical students, aided byXhosa-speaking interpreters. All carers of children aged60 months or less who had attended either ·the clinic orthe day hospital were interviewed at the exits of thefacilities.Carers were asked the age of the child, and whetherthe RTHC had been requested. The card was thenexamined to determine whether the immunisationschedule was up to date. Where the commencement ofimmunisation was delayed, or the schedule interrupted,the current vaccination status was assessed. Ifdocumen-tation was not available, the carers was asked whetherimmunisations were up to date.A missed opportunity for immunisation was definedas the attendance of a child aged 60 months or lesswithout evidence of up-to-date immunisation, whichended without the appropriate immunisation beinggiven in the absence of any contraindications.Two definitions for documented immunisation wereused: (i) strict - details of immunisation documentedon the RTHC; and (ii) lenient - details documentedon the RTHC, or history of up-to-date immunisationgiven by the carer.Children found to be incompletely immunised weretaken directly to the immunisation room. Personnelresponsible for immunisation were informed of thenature of the study, but asked not to disclose the detailsto other staff members.NolungileSample size (No.) 285Child accompanied by parent ('Ye) 90,2RTHC requested ('Ye) 90,2RTHC available ('Ye) 90,9Missed opportunities for immunisation ('Ye)Strict definition' 11,2Lenient definitiont 6,6

Far fewer missed opportunities for inununisation in an integrated child health service

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Far fewer missed opportunities for inununisation in an integrated child health service

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