Evaluation of a Child Sexual Abuse Prevention Program—Vermont, 1995-1997 FREE

MMWR. 2001;50:77-78, 87

Public health social marketing campaigns have targeted adults to prevent drinking and driving, smoking, and human immunodeficiency virus transmission^1- 2; however, adults have not been targeted for prevention of child sexual abuse. In Vermont, STOP IT NOW! addresses child sexual abuse systematically as a public health issue by using social marketing and public education to emphasize the responsibility of adults for prevention. As one component of STOP IT NOW!, Vermont sex offender treatment providers and state attorneys' offices were surveyed in September 1997 to assess self-reported abuse by adults and adolescents. This report summarizes the results of the survey, which indicate that some adults who abuse will turn themselves in voluntarily for treatment despite mandated reporting to the legal system, and some parents will intervene to seek help for their children who have sexual behavior problems even without a victim's report. Continued studies are needed to evaluate this approach to preventing child sexual abuse.

The Vermont Center for the Prevention and Treatment of Sexual Abusers, a public agency jointly funded through Vermont's Department of Correction and Social and Rehabilitative Services, sent a survey to all 18 Vermont treatment providers working with adult and adolescent sex offenders. Sex offender treatment providers were asked to report the number of persons who self-reported before entering the legal system during 1995–September 1997. Fifteen (83%) sex offender treatment providers responded to the survey.

State attorneys' offices in Vermont's 14 counties were contacted by telephone to determine the number of adults and adolescents with sexual behavior problems who voluntarily entered the legal system during 1995–September 1997. These cases were distinguished from those that entered the legal system after a child victim or an adult informed by a child victim reported the situation. Because Vermont does not track self-disclosure, it was not possible to determine the percentage of sex offenders who self-reported.

Vermont sex offender treatment providers reported that 50 persons self-reported sexual abuse before entering the legal system during 1995–September 1997. Of these, 11 were adults who self-reported, and 39 were adolescents who entered treatment as a result of a parent or guardian soliciting help. State attorneys' offices reported that eight adults who had sexually abused a child self-reported to legal authorities in five counties.

L Chasan-Taber, ScD, Dept of Biostatistics and Epidemiology, School of Public Health and Health Sciences, Univ of Massachusetts, Amherst; J Tabachnick, MPPM, STOP IT NOW!, Haydenville, Massachusetts. PM McMahon, PhD, Injury Research and Prevention, Louisiana Office of Public Health, Dept of Health and Hospitals and Dept of Pediatrics, School of Medicine, Tulane Univ, New Orleans, Louisiana. Family and Intimate Violence Prevention Team, Div of Violence Prevention, National Center for Injury Prevention and Control, CDC.

During 1993, approximately 300,000 children were sexually abused.³ Most child sexual abuse prevention programs focus on teaching children how to lower their risk for becoming a victim of sexual abuse.⁴ However, the greatest potential for prevention may be with persons who abuse or other adults who can intervene with the abuser. With treatment, those who abuse can modify their behaviors.⁵

This report underscores the potential efficacy of targeting persons who abuse and the adults who know them. In Vermont, STOP IT NOW!'s public health intervention uses three strategies: (1) a media campaign targeting all Vermont residents to increase residents' awareness of abuse and its signs; (2) an outreach campaign targeting high-risk families that provides a helpline for adults with questions about or experience of sexual abuse and provides information to agencies working with these families; and (3) a strategy to explore partnerships with Vermont decision-makers and leaders and develop approaches to prevent child sexual abuse.

Community factors may be critical to the success of these programs. Vermont has treatment programs throughout the state and within the prison system. In this setting, STOP IT NOW! can guarantee treatment to anyone who enters the legal system. Vermont also offers accessible media markets for its small population. Finally, Vermont has a coalition of victim and abuser treatment organizations that supported the introduction of this approach to prevention.

The findings in this report probably underestimate the actual number of self-reported cases of child sexual abuse because the state attorneys' offices and sex offender treatment providers do not maintain an official record of self-reports. If information or evidence was insufficient to warrant an investigation, cases might never have reached the state attorneys' offices. In addition, case-patients also may have left the state or met with a therapist not specifically trained in sex offender treatment; these persons would not have been included in the survey.

Evaluation of programs such as STOP IT NOW! will help determine the potential efficacy and need for media and outreach campaigns that focus on persons who abuse and the adults who know them. A collaborative effort between public health officials, sex offender treatment providers, and the criminal justice system in the model of STOP IT NOW! may benefit the well being of children.

MMWR. 2001;50:41-51

In 1988, the World Health Assembly resolved to eradicate poliomyelitis globally by 2000.¹ Substantial progress has been achieved toward this goal,^2- 3 and with the circulation of wild poliovirus eliminated in most of the world, attention has focused on examining the potential for vaccine-derived poliovirus to circulate where wild poliovirus has disappeared. During 1999, sequences of historic poliovirus isolates were examined. This report summaries the results of that study, which indicate that oral poliovirus vaccine (OPV)-derived poliovirus type 2 circulated in Egypt during the 1980s and early 1990s and caused widespread infection and paralytic disease. The findings underscore the need for countries using OPV to target communities with low vaccine coverage for intense vaccination activities to prevent circulation of both wild and vaccine-derived polioviruses.

During 1988-1993, 32 polio cases associated with vaccine-derived poliovirus type 2 were found in eight of 27 governorates in Egypt. Although initial antigenic characterization of the isolates indicated that they had nonvaccine-like properties, nucleotide sequence analysis (i.e., comparing the 903 nucleotides encoding the major capsid protein, VP1) performed during 1999 revealed that all of the isolates were related (93%-96% nucleotide sequence identity) to the Sabin type 2 OPV strain (Sabin 2). The isolates were not related (<81% nucleotide sequence identity) to the wild type 2 poliovirus that had been indigenous to Egypt (last isolated in 1979) or to any other wild type 2 polioviruses.³ The isolates also differed from type 2 vaccine-derived polioviruses normally isolated from patients with acute flaccid paralysis that typically are related closely (>99.5% nucleotide sequence identity) to Sabin 2.

Both epidemiologic and genetic data among the 32 case isolates indicate extensive circulation of type 2 vaccine-derived polioviruses in Egypt during 1988-1993. Several type 2 isolates were associated with clusters of cases within the same governorate, and sustained circulation of Sabin 2-derived poliovirus probably occurred in some communities. The isolates grouped into approximately 10 genetic lineages (corresponding to chains of transmission), and isolates from the same governorate usually were closely related. The extent of VP1 sequence divergence from Sabin 2 was similar for isolates for any given year, and divergence increased at a nearly constant rate from 1988 to 1993. However, the sequence diversity (4%-5%) of the early isolates suggested that circulation had started several years before 1988. Although the precise duration and extent of vaccine-derived poliovirus circulation in Egypt is uncertain because of gaps in surveillance before 1990, regression analysis of the VP1 evolution rate suggested that all lineages derived from one OPV infection that occurred approximately during 1982, and that progeny from that initiating infection circulated in Egypt during 1982-1993. The estimate of the time of the initiating OPV infection is based on the assumption that the rate of VP1 evolution was nearly constant throughout the period of virus circulation.

Circulation of the Sabin 2-derived poliovirus occurred when OPV coverage probably was low in the affected communities. OPV coverage rates increased steadily in the mid-1990s, and no highly divergent vaccine-derived poliovirus isolates have been found in Egypt since 1993.

WHO Regional Reference Laboratory, Egyptian Institute for Biological Products and Vaccine Production; Ministry of Health; Expanded Programme on Immunization, Regional Office for the Eastern Mediterranean Region, Cairo, Egypt. Respiratory and Enteric Viruses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Vaccine Preventable Disease Eradication Div, National Immunization Program, CDC.

The finding that vaccine-derived polioviruses may circulate under suitable conditions presents an additional challenge to efforts to eradicate polio worldwide.^1- 2,4 During 2000, circulation of type 1 vaccine-derived poliovirus in the Dominican Republic and Haiti was associated with 19 suspected polio cases.⁵ Nucleotide sequence relationships among Sabin 2-derived polioviruses isolated in China during the mid-1990s also were consistent with establishment of genetic lineages by person-to-person transmission.⁶

Low OPV coverage following the elimination of at least one indigenous wild poliovirus serotype probably is critical for circulation of vaccine-derived polioviruses. Such conditions permit expansion of the cohort of children who are not immune to one or more poliovirus serotypes. The threshold rates of vaccine coverage needed to suppress circulation of vaccine-derived polioviruses are unknown but probably vary by poliovirus serotype and environmental factors (e.g., population density, levels of sanitation, and climate). However, when OPV coverage rates are sufficient to prevent circulation of wild polioviruses, they probably are sufficient to prevent circulation of vaccine-derived polioviruses.⁴

Because the outbreak described in this report involved extensive person-to-person transmission of poliovirus, it differs from vaccine-associated paralytic polio (VAPP). Cases of VAPP are not linked epidemiologically or virologically to each other but are associated with separate recent exposures to OPV.⁷ However, the early events associated with the circulation of vaccine-derived polioviruses may be similar to events associated with contact cases of VAPP: an unimmunized person is exposed to vaccine-derived poliovirus excreted by a recent OPV recipient.⁷ Excreted vaccine-derived viruses often are more virulent than the original OPV strains.⁸ Low levels of population immunity may favor the selection and transmission of vaccine-derived variants with biologic properties indistinguishable from those of wild polioviruses.

The outbreak in the Dominican Republic and Haiti involved circulating poliovirus type 1; the cases in China and Egypt (and possibly infections detected by environmental surveillance in Israel [9]) involved circulating type 2 vaccine-derived viruses. The type 2 OPV strain is the most transmissible of the three poliovirus serotypes.^4,7 Because circulation of wild type 2 polioviruses probably has ceased worldwide,^2- 3 the only type 2 polioviruses infecting humans and conferring type-specific immunity are likely to be those derived from OPV.

The potential of vaccine-derived polioviruses to establish and maintain circulation has important implications for developing an appropriate strategy for the cessation of vaccination with OPV after wild poliovirus eradication has been achieved.⁴ Potential vaccine-derived poliovirus circulation also underscores the importance of maintaining high rates of poliovirus vaccine coverage worldwide. Countries using OPV should target communities with low vaccine coverage for intensified vaccination activities to prevent circulation of vaccine-derived and wild polioviruses. Countries using inactivated poliovirus vaccine should take steps to ensure high coverage rates in all communities to prevent the transmission of imported polioviruses.

MMWR. 2001;50:59-61

In the early 1990s, human immunodeficiency virus (HIV) infection associated with possible reuse of syringes and needles was reported among children in Romanian orphanages.¹ These findings led health-care workers to use new disposable syringes and needles for administering injections. By the late 1990s, reports suggested that new disposable syringes and needles had become standard for all injections. However, surveillance data collected by the Romanian Ministry of Health (MoH) during 1997-1998 indicated that acute hepatitis B virus (HBV) infection was associated with receiving injections among children aged <5 years.² In Romania, injection frequently is used to administer medication, and nurses administer most injections.³ To identify the practices that might have resulted in injection-associated HBV transmission, selected clinic and hospital nurses were surveyed. This report summarizes the findings of the survey, which indicated that although nurses used new disposable syringes and needles, other inadequate infection-control practices might explain injection-associated HBV transmission. Results of the survey were used by the Romanian Coalition to Prevent Nosocomial Infections to prepare standards for injection safety to protect patients and health-care workers from HBV infection.

A systematic sample of every ninth nurse on the Valcea District nursing payroll was selected to be interviewed about knowledge and practice of infection control and bloodborne pathogen transmission during injection administration. Interviews were conducted during October 1998 using a standardized questionnaire. Information collected included demographics, work history, type of practice and injection administration knowledge, attitudes, and procedures.

Of the 1906 nurses on the payroll, 212 (11%) were included in the sample; 180 (85%) agreed to be interviewed. Of the 180, 164 (91%) were female; the mean age was 40 years (range: 23-61 years), and the mean number of years of practice was 20 (range: 1-42 years). Awareness of universal precautions to prevent bloodborne pathogen transmission was reported by 99% of respondents; 161 (91%; 95% confidence interval [CI] = 86%-96%) of 177 respondents reported attending at least one training session on universal precautions. No respondent reported reusing syringes or needles on different patients; seven (4%; 95% CI = 2%-8%) reported that they would reuse a syringe or needle on the same patient only in an emergency; 112 (62%; 95% CI = 55%-69%) were unaware that HBV remains infectious in the environment for up to 1 week, and 78 (53%; 95% CI = 44%-61%) of 148 reported that their work locations did not have an area for preparing injections that was separate from where blood and blood-contaminated objects might be handled. Seven (4%; 95% CI = 2%-8%) were aware that following a needlestick the risk for transmission from an infected patient was greater for HBV infection than for HIV infection; 148 (82%; 95% CI = 76%-87%) reported at least one incident of lacerating a finger while opening glass medication ampules to prepare injections. Shortages of infection-control supplies, including puncture-proof sharps containers, disinfecting solutions, and single-use gloves, were reported by 128 (72%; 95% CI = 65%-79%) of 177, 95 (53%; 95% CI = 45%-60%), and 84 (60%; 95% CI = 51%-68%) of 141 respondents, respectively.

To validate the survey results, unannounced visits were made to four outpatient clinics and all wards of five hospitals to observe nurses' injection practices and adherence to universal precautions. In outpatient clinics, patients usually provided their own new disposable syringes and needles, and MoH provided clinics with new disposable syringes and needles for recommended vaccinations. However, this sterile equipment might have become contaminated with blood before use (e.g., blood specimens were collected in open wide-mouthed vials that were handled and placed on tables where injections were prepared, needles were placed in multidose vials to serve as access ports, and finger lacerations were left uncovered before preparing or administering injections).

D Popesu Chisevescu, I Mihailescu, G Popaza Mihailescu, L Pasat, Valcea Public Health Direction, Valcea; N Ion-Nedelcu, Bucharest Public Health Direction, Bucharest; MI Popa, Ministry of Health, Romania. Hepatitis Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; and an EIS Officer, CDC.

Overuse of injections and unsafe injection practices may lead to large-scale transmission of bloodborne pathogens.⁴ Although most injection-associated bloodborne pathogen transmission in health-care facilities can be attributed to reuse of unsterilized syringes and needles, results of this investigation suggest that this practice is likely to be rare in Romania. However, inadequate infection-control practices might explain injection-associated bloodborne pathogen transmission.

In 1998, almost all Romanian adults were aware of the risk for HIV infection associated with the reuse of syringes and needles.³ Patients either provided their own equipment or observed the opening of the package containing a new needle and syringe before receiving an injection (CDC, unpublished data, 1998). However, injections prepared in areas potentially contaminated with blood, multidose vial mishandling, and inadequate supplies were reported by nurses and validated by observation. In the United States, similar practices have been associated with HBV transmission in hemodialysis settings, in which frequent percutaneous exposures in a population with a high prevalence of chronic HBV infection may facilitate nosocomial HBV transmission.^5- 6 In Romania, where chronic HBV is endemic⁷ and injections are often used to administer medication,⁴ these practices might explain injection-associated HBV transmission in the absence of syringe and needle reuse. Because most of the nurses interviewed were unaware that HBV persists in the environment for at least 1 week⁸ and that the risk for transmitting HBV through injections can be up to 100 times greater than the risk for transmitting HIV,⁹ the nurses might not have perceived the risks for HBV transmission associated with these practices.

The findings in this report are subject to at least two limitations. First, logistic and resource constraints limited the survey to one district; however, reports suggested that nurses in Valcea had similar education and experience compared with nurses in other Romanian districts. Second, survey results were validated by observing nursing practice in clinics and hospitals. Because the nurses were aware they were being observed, behavior might have been modified.

In 1999, the Romanian Coalition to Prevent Nosocomial Infections held a multidisciplinary conference to define standards of injection safety. Recommendations included establishing dedicated areas for injection preparation, appropriately handling multidose vials, placing puncture-proof sharps containers in each room where injections are given, and covering lacerations. An integrated information, education, and communication campaign based on these recommendations and targeting patients and health-care workers was launched and an evaluation of the intervention is being planned. Activities conducted by government and nongovernment organizations aimed at achieving safe and appropriate use of injections are being facilitated by the Safe Injection Global Network (SIGN). Additional information is available from the SIGN secretariat, Department of Blood Safety and Clinical Technology, World Health Organization, 20 Avenue Appia, CH 1211, Geneva 27, Switzerland, or from the World-Wide Web, http://www.injectionsafety.org.