ISBN 0 7992 0716 0 - University of Cape Town

Cape Town

MIDs 1maIn1sat1on anpaigra - 'Dle T1nt:DoJalo uperienoe

by

Eric Budl, Ehn1ka Ntlc:D ^I Helen Nyath1

carnegie

Q:lI'\ferenoe PIIIper No. 200

13 - 19 April 1984

ISBN 0 7992 0716 0

.id.,y bet •• on •• Is,rvit Ind Tun.u. It is typical ~ . . ht.ld .ith 1I.ited water .nd poor .grinlt.'I1 potential. 152.000 p • .,1t Ii .. In ,'IIaI.'s 57 .illa,tI vhich war, i. sire .nd infr .. tr~ot\lr'. Hulth str.ictl

,r,

u"~.rd ... l.p.d ... ~ c •• ,ris. ou 260-hd hos,ltll (Tlntsulo) ... hoalth coatre. ton cllnlos .n~ I .o~ilt oUnlc.

1liiy did Wits •• 4Ical School h u n 1" .. I •• d h ... ? It.as~, both dul,n .nd fate. At Wita v. h.d p.oplt interested In rvra\ health .n4 • hn.faotor (An,lo ... riean Chalrolft'l ro"d) ,r.,ar.d h sponsor rur.1 h •• lth •• rk. Tho , ... r" •• "t hIS ,"courl,od th •• rious •• died ICho.h h bt .... .in.h.d I"

rural h .. lth car. Ind has " .. i,n.ted ,sch.oh h ,.rticular "ho •• l."ds".

So v. be . . . . in.olv.d In ' ... nk_l_ .nd tho Health S . . . icII D ••• lop .. "t Unit ("SOU) • • ,roj.ct of the Mit.

D.p.rt .. nt of Co •• "nit, Health . . . . OIhblish.d. Th. objecti ... of tht U.it ... tht tr.inin, of .ppr.priate health ser.ice l"t.ff. tho flp.nsion .nd develop .. nt of clinic .. r.lcu .nd tho cr .. tlon of • h .. lth .... ice vhieh il c ••••

"it,

s.pportive .nd r"po.si •• to 'local ".eds. Tt s.ccOld .0 "Old tho loodvill. s_"ort .nd rupect of tho couunlt, ."d the vh.lthoart.d b.cHnl .f tho •• iltin, h .. lth IIr.ice.

Thil p.por ."d tho .th.r. of tho HSOII .r . . . fl.ction ••• naly .... r.c ... d.ti.n. Iftd id . . s I"d ... tho product .f lur 'flrat tvo ,lIrs' uptri.nc.. Oplni.ns uprossid Ire h .. d 0" tho critical .naly.is of h.rd d.h On tho Ino hand Ind on porsonal i.pr.ssionl on tho oth~r. Whlto .. r thl o,inion • .it h .. bltn Icq.irod by fir.t h.nd .nd s_stained p.rsonal npori.nce.

Th. p.p.ra co.or thrtt .sp.cts .f our •• p.rionco:

1. Th. Stat. of H .. lth Ind Health Clr. in "h.la a. Health .nd H.alth Car. In "hala .n .. ir.ltv.

b. Th. Nutritional StatUI of Childr.n 1 - 5 ,urs.

2. A Critiqu. of SOl. Health Ser.ic. lnttr •• ntlons in "hala

a. Co .. unity Htllth lIorker. I. "hala P.r •• rsio. of a progr.ssiv. Conco,t?

b. How vtll do Ollr Rural Clinici Function?

c. , Re.ieving the Htllth Centre Policy.

d. "obilo 'Clinic. : Vh.t Cln and do tho, Achie.07 3. Health Str.ice lnter •• ntions b, the Vits HSOU

•• Do Prioar, Htllth Clro NIIrslI in Gllank_lu pro.ido S.cond Clan'Che., Clrl h the Poor?

b. C •• good Tuborcul •• is S.~.ic .. b. pro.id.d In the FICt of Povort,?

c. School Htllth Servi •• s I Probl •• s Ind prospoets.

d. IIa .. I .. llnh.tio. C'.palgnl - Th.

n.ts ..

l, Exporienco.

Tho ... g. Is thlt:

- Heal th Clr, i. "h.la is In.d.qu.te.

This elrt ca. b. I.provld without pr.c.ding ch.ng .. in tho pro .. nt tco.oaic •• d ,olitlcal systo.s.

- Such I.pro .... nt is H.ited b, social •• cono.ie .nd political constraints which Irt tho root cause of ._ch Illn ....

- It i. worth .orking In "ho •• land" h .. lth .. rvicos bec.use of what c.n b. Ichlt •• d.

In .ckn.vledging III vho ha .. work.d in or vith HSDU it .ust b. r •••• b.rtd that health ..

"-.i ..

d.velop . . nt Is • h •• offort. ".n, of tho p.ople of Khala. tho ho.pital stiff. ,rillrily 01 .. Steph ••• o. as .",erintnd.nt Ind tho couunity h.alth n_rs ... Or Eriel Sutttr Ind tho sup.rinhndents Ind stiff of Gazank_lu'. other hospitals. tho htllth d.p.rt .. nt I.d b, Or Roos and.

aor. r.cently. Dr Aob.rt, and the Chief "Inister of Glunkulu h ... all contributed to the .. tablith •• nt Ind dt •• lop •• nt of tho Unit. Tho Chlirlln'. Fund of Anglo A .. rlcan and th Unlv.rslt, .f' tho IIitut.rs ... 4 ha •• pro.lded tho infrastructur.. '

Th. action has co •• froo Anit. and lob lack.ntOIl. Eric luch. Rob C.llins. C."ic d.

".r.

Cliv. hlan. Vic Sord.u •• IIorr,1 HI .. ond. Thoko "al_lok •• Shirlo, IIlIvan, •• ,i. Sanlleliv. lltehl.

Oip_o 1I01OVI. Robert W.u,h ud lIerrick Zwartn,tein.

JOHN SUR DIRECTOA - HSOU IIARCH 1984

MASS It1~lUNISArION CA!~PAIGNS - THE TINTSWALO EXPERIENCE

Eric Buch, Ennika Ntlemo and Helen Nyathi

Tintswalo hospital is situated In the Mhala district of Gazankulu in the Eastern Transvaal. The hospital serves 152 000 p~ople who live in 57 rural villages. The villages are spread over an area of 1204 sq.km.

Nhala is. a fairly typical homeland area. Poverty and poor socio-economic conditions are widespread. The population is largely dependent on income from migrant 'labourers. Adult literacy levels are low. Transport is lillfted and expensive. Water is scarce.

Health services are based on the 260 bed Tlntswalo hospital, fts ten clinfcs and one health centre. There Is no village level health service infrastructure. immunisations are performed at weekly child health clfnlcs.

The immunisation, servi-ce Is free,. but 'dlstances mean costs fn transport and tilne.

Our involvement in mass immunisation ca,npaignsemerged In response to the polio epidemic of' 1982. The first campaign started. In June 1982. Following. Its success, we ran a second campaign. In September 1982 and a thfrdln May 1983.

We would like to describe how we delfvered these services, and our results. We will then review our experience and comment on the role of mass flllllUnfsatfon campaigns.

-

.'

PREPARATIONS FOK THl FIRST MASS IMMUNISATION CAMPAIGN

The Decision

On the 17th June, ,SiX week·s-after .the epidemic started, Tintswalo was Informed about it, and requested to fmmunlse against polfo: As we had no details of the epidemic, and were" not giv!n information on polio or on how to cop,e with such emergency situations our first step was to establish this background. We did, and the information was analysed by senior hospital staff. On the 21st June we

~ new that we were at ri sk of an epi demi c In our area as we recognised the uncontrolled spr2~d of the disease, t~e inept attempts to control It, and the

f~ct that we milY have used imrotent vaccine in Mhala.

We had to f.auntse as

aI"y

chfldren under the age of 5 as soon as possfble.

We decided not to fmunise agafnst other dtseasi!s at thts stage. lie thought that ff we dfd. we would lose our fepact and overextend our resources. If the first campafgn was successful we would mount further campafgns.

We decfded that

is

was IIIOst appropriate to use a mass campafgn strategy. We agreed to fnclude extensfve education. and to I1IIke servfces accessfble to people by illlllUnfsfng in the villages. rather than at the cHnfc. The campaign would begfn a week later to allow time for proper preparation.

We used a three day. three-step strategy in each vfllage.

Day 1- A village llleetfng was held to fnfonD people about polto. the epfdemic. and our fmmunfsation plans.

Day 2 - Education teams visfted people on a door to door basis to inform them. They also answered

a~

questfons and delivered fnformation pamphlets.

Day 3- Immunisatfon teams fmmunfsed at an appointed place in each village. Mothers queued uP. got their Road to Health Charts fflled fn. and their children fmnunfsed.

We added radio broadcasts to thfs strategy to help inform people and generate fnterest. News reports. a short advertisement and anfntervfew wfth our staff were broadcast.

The preparatfon

Durfng the week between decfdfng to lIIOunt the campafgn and actually starting it a lot of work had to be done.

The educatfon teams were trained fn a two day worltshop run by the hospital's prfmary health care nursing students. Subjects fncluded polio. the epidemic.

and the campaign. We used adult education methods and hoped that our students

would

do

the same. Role plays and group dfscussions wereextensfvelyused •.

3.

The main messages for the campaign were:

There is a polio epidemic threatening us Po 1 i 0 is ...

Pol i 0 -can be prevented by

There is an immunisation campaign

People are encouraged, but not forced to attend

There is no puni shment for choosi ng not to have your chl1 dr. n irmiunised.

The training workshop also focused on our attitudes and our approach to people. We stressed the importance of making people feel comfortable, and of giving them enough time to ask questions. The importance of truthful answering was emphasised. We explained that the health services had failed to immunise adequately in the past and that we ellen wanted children to be re-immunfsed, because we feared that they may have received ineffective vaccine. We explained that our new vaccine had been well cared for. We would not blame rnothers for not havi ng had thei r chil dren fmmuni sed before,as it was not thei r fault. Thi s approach to people is fundamental to bull di n9 the trust on which a successful mass immunisation campaign is based.

An information pamphlet was prepared to be delivered to the homes by the education team. (Appendix I) It explained:

What Polio is.

What happens when someone gets Polio • . Why there is a campaign.

How we plan to stop-Polio.

How immunisation works.

Why shoul d chil dr,'1l who have been immuni sed be re-ir.rnuni sed.

Where people can get their children immunised.

We started trying to build team spirit and teamwork. Regular -team meetings were started to establish an open forum for discussion of problems, and sharing news on the progress of the campaign .

. '.

Infornldtlon networks were established. Hospital staff were informed and asked _to spread the word. Chiefs and headmen were visited to arrange, village

meet i n;Js and radi 0 broadcasts were organi·sed.

In spfte of the appar.nt national shortage, vaccine suppHes were arranged.

The cold chain was to be IIIIfnhined by freezer storage at the hospftal, and cooler boxes with tce blocks for dafly supplfes.

Four health educatfon teams of 2 nursfng assftants and 2 vfl1age women were set up. (When

we

refer to vfllage Wo=In, we aean mothers fn the comlUnity who were in no way prevfously linked to the health servfce.) The four imunisation teaas were aade up of a cOlCllUnf~ health nurse, a health fnspector, and a secondary school student.

By 28 June we were rea~ to start. We had planned to ffnfsh the campafgn fn 15 workfng d~s. By

16

July we were ffnished. Our results and experience wfll be discussed later.

PREPARATIONS

FOR

THE SECOND AND THIRD MASS IMMUNISATION CAMPAIGNS

Following the success of the first campaign, we followed up with second and thfrd ones. They were needed to ensure good protection agafnst polio and because we had not yet immunised agafnst all the other dfseases.

The approach was essentfally sfmilar to the ffrst campafgn. As we were not in such a rush we could run these campafgns over 5 weeks. Needless to s~ we were better organfsed and had learned frol1l our experience. We dropped v11lage meeti ngs as they had been unsucceSSful. Our educatf on tealls were aade up of village women only as they were by far the best educators, and we increased thefr number as they had previously been overworked.

THE RESUlTS OF THE MASS IMMUNISATION CAMPAIGNS

30 233 chfldren were illlllUnised in the 57 vf1lages durfng the ffrst campafgn.

32 088 and 35 871 were flllllllnfsed 'fn the second and thfrd callpaigns respectfvely. Thfs fs more than the nucber of chfldren who were belfeved to be in the vfllages.

I

I

5.

fhe

nUfIlul:r of children illlllUnised 'agdinst each disease is presented In Table I below:

TABLE I

Nur~BER

OF CHILDREN lfotIUNISED AGAINST DIFFERENT DISEASES

Immunisation against . First Campaign Second Ca!Rpai gn Third Call1Palgn

. .

Polio 30 233 32 088 35 871

Diphtheria, Whooping

Cough and Tetanus - 8 329 14 835

Diphtheria and

Tetanus - 23 119 21 652

Measles - 29 323 18 053

Tuberculosis - Incomplete 9 026

data

·The estimated cost of the first campaign was R7 100 and of the second and third R13800. Details of these estimates are presented In Table II below. Most of

·the costs fell within the routine hospital budget.

TABLE II

MASS lfotIUNISATIOH

C~~PAIGN

BUDGETS

First Second &

Third

Vacd ne R2 000 R 7 500

Transport R 750

R

600

Food R 300

R

650

Workers (Permanent) R3 000 R 3 000 Workers (Temporary) R 750 R 1 750 Printing (Education

Pamphlets) R 300 R 300

- - ---

R7 100 R13 800

~ -

~~---~

....

,

A REVIEW Of THE EXPERIENCE' Of' THE FIRST ~SS UflUNISATlON CAMPAIGN

We reviewed our experience during and after the campaign. The fnforaatiOll that we now present fs an Iccuculation of the thoughts of all our workers.

The training workshops were successful. Doing role plays and practicfng fn the hospital were the best teaching aethods. The education teaas did well in their approach and fn their education practice, but" struggled with adafnfstrative tasks such as reading timetables and defining the division of

work.

lie never thought of teachfng these subJects~

Village aeetfngs were disappointing. In the IIIc1Jority of vfllages attendance was poor. In some the headNn did not even arrange a llleeting. Furthennore, the behaviour of powerful people at the aeetfngs inhibited open discussion'and questions.

Door-to-door education was the key to success. The fact that we visited people in their own homes proved to them hoW important the campafgn was and allowed them the freedOfft to ask questions. Not only did the educators deliver our messages; they also dispelled many IIIYths. For example, some people believed that pol i 0, was a disease of ,Shangaan speakers, and therefore Zul u' and Sotho speakers did not need to be i"""nfsed against It. Others had been told that I~nisation would poison their'children.

The village women were the best educators. They communicated easily and In a natural way wfth their fellow villagers. They were not elitist and showed the greatest respect for people. The villagers were mo're at ease wlth'thetll and more apt to ask questions and criticise the health service. . .

The immunfsition tea",s worked well, albeit a bit roughly at times.' They 'gave polio drops, kept statistics, and filled in Road to Health Charts at

a

~ate of up to 250 per hour.

Ensurin9 proper queueing was a problem. One persOn jUlllpin9 the queue started the ball rolling, and If nothfn9 was done about It,' the situation became ' uncontrollable. We found that those people who consider th ... selves e1fte (usually those with high education or Incomel are the ones who thought they didn't need to queue. We solved this problem by escorting th ... to the back.

They were obviously embarrassed, and our ffnn response discouraged others.

7.

Tlli s al so helped improve our credi bi 11 ty, as the average vi 11 ager saw that we tlid not rHour the rich or the educated. It also helped people to be IIIOre patient.

Radio announcements of immunisation venues and campaign results were helpful.

Ho',/ever, we should have taken more care with the educational component of radio mess,lges. We found that some people had mfsunderstood them. Even worse, conflicting messages were aired. For example, while we were explaining that the epidemic was due to health service inadequacies, the radio said that it was because mothers had refused to bring their children for inrnunisation. This made mothers feel scared, ashamed and alfenated. and made our Job more di fffcul t.

The education pamphlets served us well. For chfldren it was an opportunity to recei ve some readi ng materi al and for grandparents a chance to get thei r

~randchildren to entertain them. It also gave those who were not home when we called an opportunity to become fnformed. The fact that the printfng was 1,lrge, the language Shangaan, and the words used sfmple. all contrfbuted to the success.

The review up to now may make it sound as if everything went like clockwork.

As in any progranme, there were ups and downs. especially fn the ,ly stages. The daily team meetings helped us overcome problems. and as our experience grew, so did our skill.

A REVIEW OF THE EXPERIENCE OF THE SECOND AND THIRD MASS IMMUNISATION CAMPAIGNS

The second and third campaigns ran more smoothly. No problems resulted frolR our decision to drop village meetings. The idea of using education teams made up of village women only. proved to be a good one. Radio fnfonmatfon was

more

accurate, but not as consistent as in the ffrst campaign. This was probably explafned hy the fact that there was no epidemic. We added a song about inmunfsation to our educational progranme. OUr education teatll left each day singing about our theme.

010 THE MASS IMMUNISATION CN4PAIGHS STOP DISEASE AND SAVE MONEY?

No cases of polio occurred in Mhala during the epidemic. Four cases of

·paralytic polio were admitted to Tintswalo frOM nearby·areas outside MIIala. We have adRiftted

18

measles a·nd 9 whooping cough cases since the· second campaign. This cOlllPares with an average of 113 measles admissions per annUl"

from

1979

to

1982,

and

10

of whooping cough. No cases of childhood tetanus have been admitted since the second campaign. Details are presented fn Table III below:

TABLE I II

ADMISSIONS OF IMMUNISABLE OISEASE TO TINTSWALO

1979 - 1982

TOTAL FROM MHALA

Measles Whooping Polio Measles Whooping Polio

Cough Cough

1979 22 15 0 8 6 0

1980 150

3

0 72 1 0

1981 169 7 0 98 6 0

1982 109 12

4

55 6 0

1983 19 9 0 9 3 0

Note: The low number of measles admissions in

1979

fs because hospital policy was to not admit children with measles unless they ,were seriously ill. This was to prevent an outbreak of measles amOngsthospital1sed

.

^{" ~}

children.

We cannot conclusively prove that the illlRUnfsation campaigns prevented the polio epid~nic spreading to our area. However, it does seem likely •. We should point out that durfng the campaign we ilm.lnised ~re than 8000 Children at ~he

hospital. They caae from nearby villages in Lebowa to which we Ire not allowed to go to. Thfs may have had the effect of blocking the spread of p·olio southwards by creating a belt of immunised children.

9.

H"

CMlnOt prQvl' tlMt we would

h'lV~

alilnitted more cases of

l1It'a~le~. bllt

the

notdble

drop in the number of cases admitted in 1983 is probably due to the campaigns. This argument

is

strengthened by the finding that althQugh 25, 23 and 22 cases of measles were admitted to Tfntswalo in the

.3

RIOnths before the 2nd campaign, the number dropped to

6,9

and

0

after it.

One

thing we can say: the children in (lur area are now flllllUnfsed.

The cost-benefit of the mass immunisation strategy fs not fn doubt. A total calculation of benefits would need to include costs to the famfly (e.g.

transport, mothers away from work), cost of care at the hospftals and clinlcs, and the long term cost of caring for disabilities. As this complete analysfs is impossible to do, some examples of savings will be given.

The total cost of the first immunisation campaign was much less than the cost of ensuring long term treatment for a slngle case of paralytic polio.

Using the average number of hospital days for measles from 1979 - 1982, and the cost per patient per day at Tintswalo, measles admissions cost us R7623 per annum to treat. This is half the cost of a campaign.

The cost of all three campaigns

is

covered

if

we have prevented a single child going blind as a result of a vltamin A deficiency following

measle~.

IIHY IIERE ItE

SUCCESSFUL?

lie believe that our campaigns have been successful. After the first campaign we tried to analyse the key factors that led to our results. This analysis is obviously subjective, but we believe it

is

correct. We suggest five main reasons:

I nformed parents

The extensive information, delivered in a caring manner by trained staff using approprhte educational methods was vital. Especially important was the fact that our educators di d not just tell people to get thei r chfl dren· immuni sed.

but gave them enough knowledge to make an informed decision.

Easy access

Easy access to the iMmUnisation points was critical. People neither had far to walk, nor to pay for transport. The rand

or

two that transport costs is

b~ond

what IIIOst people can afford. Because the services were fn the village, grandlllOthers were able to bring their grandchildren, and children thefr baby brothers and sisters.

Trust

As

ma~

villagers do not really trust the health service, we had to build this up in a short time. Certain strategies helped. Two days with person-to-person contact in the village before fllll1Unisati?n was the key.

the victiiD is often blamed for the circumstances

In a deprfved society fn whfch

th~

find themselves. We rather emphasised health, servfce faflure.The fact that people near Mhala were threatened and punished for not having had their children fmmunised added to the alienation that alreadY existed. The fact that we made it clear that there would be no punishment and that parents had a free choice helped to remove some of thfs.

Teamwork

Our team approach kept our workers hi ghly motivated. Thei r certainty of the value of their work, their adequate trafning, and the progress and problelD meetings helped ensure maximum effort.

Vacd

ne

Despite shortages in other nearby homeland areas, we managed to arrange an adequate supply of vaccine. Without ft we could not have immunised.

After the fl rst campai gn we beli eved that we had demonstrated that

if

peopl e

are given real access to services, they will use them. We belfeve that there

is no such thfng as -, co;RUnity of fgnorant mothers who refuse to bring thefr

chi 1 dren for illl1lunisatf on, - but rather that there are Inany rural CIOthers who

have not had the chance of becoming adequately informed, or the opportunity of

receiving health care near their homes. Many people doubted this assessment,

and suggested that

we

were only successful because of the panic during the

polio epidemic.

11.

However. thl.' f df; t thilt we i mmuni '.cd more chl1 dren f n the second call1p.llgo than i /I the fi rs t, and more f n the thl rd than I n the second, sugges ts that our analysis is the correct one.

THE ROLE OF MASS IMMUNISATION CAMPAIGNS

The simplicity and cost-benefit of mass Immunisation campafgns telllpts one to view them as a solution to immunisation services In rural areas. However, we do not view them as a solution, but rather IS a means of buying tfme untf1 we' can provide comprehensive child care by means of regular chfld health clinics In each vf1lage. We believe that every child Is entftled to such a servfce, and that this should be our go~l. Anything less amounts to cheap care for' the poor. However, we do not want epidemics of fllllllunfsable diseases fn the meantfme, and so we use mass Immunisation campafgns.

':-j(~-9~~~~-i- si~eiQ--hi l<u '~9'J1<~--;~ru;}-'~~~;~-~;~~~o t!)a Poh'o.· " .

. ~~(a n::o(!)u{(so wo Pofl'o hi -lliOtu'seio ma-ll1onsl 90 murh; eflon'U;I'ni

^ll'() nIt"

;~,al\i tJ {arlelc Ku f'r1ini:o

J

LeX'" a ishulela

LI

.faneJe l<u tIhcl4

Q

:<cma MaL

\ ," t

J,1}';(1r:1U flO

Kambe ' ;

,!(ulani 'o!(o

I1'WQrlQ

a k'ume f)~LUUUSO lowu .. a

^f'ti0

3(£. or.sa !<,'lo:l)iwl hi

^Vll'le

b)i. - .

(-\NA HI VAH I VANA LAVA fANE:LAKA KIJ K()J'IiA NSAlr.f{ITJS(

OI,'1U '1<1/\ POLIO? .

roO lava va su~ela!<a e!<a t{nhl11ef.i -uinbfmi :<0 .[j'!<Q €~O i$e!lu tva malem/;t

/AMA NSAWUTISO. LOv./U 'v-JU k'U~'lEKA k'~/IH I?

' - '

[f.J'k'!i{Ji:<I'

^'flQ

Ie 5LUibedihele

SCl,:Q

k'a n'wlna .

. b'j·tw;.dzr.en i :(0 r.Jha!a k'u t.a va l1i nf.!aUJQ wa nsaWll::Jso lowu ,-sa -La -rCJ~

fica hI rMsan30 IHi1:<Lul1Jo

vo

ri' I<arhi' va

SntU(;-LJso V(J(I,Q

~

^.

Ku fu'

^Va

niil'nh!ef'-g e1 e-l.

Dno _

emu9Qfl9eni

UillO'v;fl..f)O"j WUn'WQIlQ

ku

JO'lI.J5e!a

hi ·La IlsQwuiJSO

tlJa

Pol:'-:;),' .

c5iku JQ nSQwu-tfso rni ta tf'l[siuIQ wona e~(.) -bi1hI-'9 zJeiafltl ~j to m:r:

'1

radl'O modyarnbo mOf}'u.:a:'lQ

(!tl

NlOnwanQ. . .,

AN A LO!(O N }""ANA A k'UiV!I LE NSAW{ffISO. tk~

}<ARH I Lo\;vU NGrA H ur-./nZA HI f'j\[f)Lt\ Yr~rc-i<.E-'~r

1---. - _ ~

ni hi leswi k'u IljQ no niofljU wa PolI'o swa cnt.5tua !~5wa!<u no h{n'(wa'lo va t Ihel~, \tI k'uma nsawulfso hi VLl1'It.sn!';Q •

rUNANI KU SlVELA POLIO Et<i\ VANA \ 'WINA N I LEMU6-ANG-EN I WA KA N'VJlr·

I. KU -:VISA .. VANA VA N'VJINA VA. YA-:..

Uf'tlA N5AWUTISO WA POLIO 5"'1£.5\\/1

i.~Ll __ ~~_' .. ~i~:C:S?:_~_~Nj~ 1= CJl;. I U_

'/', :Ji Ll e~ i hl(!Ij-::h2ni xa Hilovi YO h lose.r"ile hi vuvCJbji b~q PotlO

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