CONTRA-INDICATIONS SCREENING

Evidence indicated that the EPI program did not incorporate adequate measures for contraindications pre-screening and post-monitoring.

• All infants received the vaccines regardless of their weight or nutritional status (only one village indicated that vaccines were not given to infants severely underweight, and only one province reported post-vaccination monitoring of infants under 3 kg).

• Actual nutritional status assessment does not appear to be conducted on infants (excepting the body weight factor) before administering vaccination. • There did not appear to be any procedural requirements for checking family

histories to determine whether there existed any history of neurological disorders before administering vaccination.

The official view historically held and still articulated by the World Health Organization (WHO) is that both the provision of screening for contraindications, and post operation monitoring for adverse reactions are uncalled for in the context of Developing World EPI campaigns. The underlying rationale has been that the life saving benefits of EPI so far outweigh any risks, that attention to potential risk factors and the potential for vaccine induced damage in vaccinates remains impracticable, and thus a non-issue.14

Despite this unqualified optimism, according to information provided by CIDA's Health and Population Directorate sector, the WHO effective October, 1990, instituted a policy for "adverse event monitoring" in Developing World Immunization activities. A definitive policy statement on this issue titled Monitoring of Adverse Events Following Immunization, has been available since April 1991. (The implications of WHO's recognition of the significance of this issue in setting UCI/EPI research, monitoring and evaluation priorities should be apparent.)

It is thus important to point out that there is by no means a consensus on this issue within the Bio-science community (including the inconsistencies exhibited in the public pronouncements, and policies of the WHO). In one of the most recent scholastic manuals available on immunization practice, noted authority, George Dick- -Professor Emeritus of Pathology, London University--provides the following cautions relative to the traditional assumptions of the WHO:

• Before considering immunization it must be determined that the disease in question is of sufficient severity, frequency or other importance to justify immunization against it. Furthermore, "if the infection is readily treatable, there is seldom justification for immunization."

• "immunization is indicated only when the classic methods of control are [demonstrably] impracticable or unsuccessful."

• Before any vaccine is introduced "there must be good evidence that the vaccine is effective and relatively safe . . . Sufficient time has not yet elapsed to predict with any certainty the durability of immunity with the live virus vaccines, which are now in common use, such as poliomyelitis, measles . . . [etc.]"

• "The best type of active immunization follows a clinical or subclinical natural infection. With many diseases this often gives lifelong protection at little or no cost to the individual or to the community."

• The pre-immunization era declines in infectious diseases "should make one careful in attributing changes in the epidemiology of some diseases to the result of a specific treatment or immunization."15

He further confirms that in the following conditions, the EPI vaccine as noted should not be administered. (Obviously pre-vaccine screening measures must be in place in order to ensure that these guidelines are met.) Dick's recommendations follow on Table A.