Evaluation of Acute Flaccid Paralysis Surveillance ...

Sciknow Publications Ltd.

International Journal of Epidemiology & Infection

IJEI 2014, 2(2):36-42 DOI: 10.12966/ijei.05.04.2014

©Attribution 3.0 Unported (CC BY 3.0)

Evaluation of Acute Flaccid Paralysis Surveillance System in Sanyati District, Zimbabwe, 2013 Donewell Bangure1,*, Daniel Chirundu2, Humphrey Ndondo1, Mufuta Tshimanga1, Notion Gombe1, and Lucia Takundwa1 1

Department of Community Medicine, University of Zimbabwe, Avondale, Harare, Zimbabwe

2

City Health Department, Kadoma City Council

*Corresponding author (Email: [email protected])

Abstract - A review of the AFP investigation forms for 2012 indicated 4 cases of AFP were investigated in Sanyati District in children less than 15years of age. All the 4 reported AFP cases had forms that were incompletely filled. One case had only one stool specimen collected instead of the recommended two. According to the AFP surveillance guidelines in Zimbabwe the Sanyati district failed to investigate the minimum expected number of suspected AFP cases for the year 2012. Descriptive cross sectional study was conducted. AFP notifications forms for the period January 2009 to December 2012 were reviewed. A total 51 health workers were interviewed. AFP notification forms were reviewed for completeness and timeliness. Data were entered and analysed using Epi Info 7. Health workers interviewed were 51 and 59% were females. Median age in services of health workers was 5 years (Q1=3; Q3=13). A total of 18 health facilities were visited out of 23 in Sanyati district. Those with poor knowledge on AFP surveillance were 5(10%) and most had average knowledge constituting 33(65%). About 42(82%) were using the AFP surveillance data locally. Those that had surveillance meeting at their facilities were 14(28%) and 7% had meeting minutes available. About 28(72%) indicated that AFP surveillance data is being used to plan awareness campaigns for the community.Thirty one percent of the respondents had some public health actions taken based on AFP surveillance data collected. Case definitions were only displayed by 16 clinics. AFP reporting procedure was not available at all the clinics in Sanyati district. Private institutions in Sanyati district were not participating in the AFP surveillance. Knowledge of health workers on the AFP surveillance in Sanyati was average. The AFP surveillance system in Sanyati district is useful, simple, stable and sensitive but however the system is not representative considering that private institutions are not involved in the AFP surveillance system. Keywords - Acute Flaccid Paralysis, Sanyati District, Zimbabwe

1. Background Acute flaccid paralysis (AFP) is defined as any case of new onset of hypotonic weakness in a child aged less than 15 years of age. This includes possible illness due to Guillian-Barrésyndrome, transverse myelitis, and traumatic neuritis, viral infections caused by other enteroviruses, toxins and tumors. In the early stages of the disease polio may be difficult to differentiate from other forms of AFP. Therefore, to ensure that no case of polio goes undetected surveillance targets a symptom (AFP) rather than a specific disease (polio) (WHO, 2012). AFP surveillance is the intelligence network that underpins the polio eradication initiative. The objective of AFP surveillance is to detect poliovirus. It is also the key to detecting re-importation of poliovirus into polio-free areas. The quality of AFP surveillance becomes crucial in countries approaching the final phase of polio eradication and forms the basis of the documentation needed for certification of polio-free status. All cases of AFP in children less than 15 years and all cases of suspected poliomyelitis in individuals of any age should be reported. All AFP cases should have a full clinical, epidemiological and virological investigation (WHO, 2012) In Zimbabwe AFP surveillance was introduced under the Global Polio Eradication Programme where all districts in the country are to complete a surveillance report each month, even in the absence of AFP cases (zero reporting). AFP surveillance should be sensitive enough to detect at least two cases of non-polio AFP for every 100,000 children under-15 years of age. This parameter is used as a measure of the sensitivity of the surveillance system. In Zimbabwe when the clinician detects a case of AFP, the National Virology Laboratory stationed at Parirenyatwa Group of

International Journal of Epidemiology & Infection (2014) 36-42

37

Hospitals should be notified immediately by telephone, so that no case of AFP goes unreported. An AFP investigation form should be completed and returned to National Virology Laboratory. At least two stool samples, taken 24 hours apart and within 14 days of the onset of illness should be collected from at least 80% of these cases. These stool samples should be sent to the National Virology Laboratory for appropriate virological investigation at a temperature of +2 to +8 degrees Celsius and should reach the laboratory within 72hours. Detailed investigation of suspected polio cases should include clinical, epidemiological and virological examination as well as a follow-up examination for residual paralysis after 60 days. A final classification of the case should be made by a committee of experts on the basis of these examinations. The National Virology Laboratory collates data received from all districts and reports weekly to the World Health Organization. Sanyati District has a total population of 48,459 of children aged less than 15 years. On average the district must investigate at least 1 suspected case of AFP per year according to the Zimbabwe targets. Sanyati District has a total of 22 rural health facilities, 1 mission hospital and Kadoma General Hospital. Zimbabwe has set a target of Acute Flaccid Paralysis (AFP) case detection of 2 suspected cases for every 100,000 children below the age of 15 years. Ninety per cent of AFP cases should have two stool specimens collected 24-48 hours apart within 14 days of onset of paralysis. Stool specimens to the National Virology Laboratory with 72hours of collection at 2-8degrees Celsius. Sanyati District has a total population of 48,459 for the less than 15 years. On average the district must investigate at least 1 suspected case of AFP per year. A review of the AFP investigationforms for 2012 indicated 4 cases of AFP were investigated in Sanyati District in children less than 15years of age. All the 4 reported AFP cases had forms that were incompletely filled. One case was investigated after 14 days and no 60 day follow up was conducted. Two of the specimens were submitted to the National Virology after 72hours. One case had only one stool specimen collected instead of the recommended two. All the 4 cases that were investigated in Sanyati were classified as stool in adequacy. All the 4 suspected cases in 2012 were supposed to have 60day follow ups, but they were not done. According to the AFP surveillance guidelines in Zimbabwe the Sanyati district failed to investigate the minimum expected number of suspected AFP cases for the year 2012. Active AFP case search visits to high priority areas were last done on the 26 th of June 2011. Sanyati district is not following the country‟s AFP surveillance guidelines and there is need for corrective action. Since polio is being targeted for eradication, failure of Sanyati District to reach its target will result in the country failing to meet its target and this will derail the polio eradication programme, so there is need to evaluate the system so that national and WHO targets can be achieved. Sanyati district is failing to submit specimens to National Virology Laboratory so there is need to determine the reasons because the specimens are being classified as stool inadequacy.

2. Methods We conducted a descriptive cross sectional study. The study was conducted at health facilities in Sanyati District. The study populations were nurses, environmental health technicians, health information officers and doctors working in Sanyati District. Sanyati District Health Executive participated as the key informants. AFP notifications forms for the period January 2009 to December 2012 were reviewed. A minimum sample of 49 participants was required. Minimum sample sizes of 16 AFP forms were randomly selected from the health information department to assess for completeness and timeliness by checking the day they were filled at the clinic and date received at the district office. All the hospitals in Sanyati District that is Sanyati Mission Hospital and Kadoma General Hospital were selected. In Sanyati district there are 22 health facilities and 18 were selected randomly into this study. Nurses and environmental health technicians on duty on the day of the interview in the rural health facilities were interviewed. At Kadoma General Hospital and Sanyati Mission Hospital at least one health worker in each department (OPD, FCH, Laboratory, and all admitting wards) found on duty was interviewed. If on the day of the interview there were more than one worker on duty, a lottery method was used to select the respondent. Cards written “yes” or “no” were used. One health worker who picks a card written “yes” in a hat, amongst n cards, (where n is the number of eligible respondents in the department, and n-1 was the number on cards written “no”) was selected. Sanyati District Health Executive members were selected as key informants. The matrons from Kadoma General Hospital and Sanyati Mission Hospital were also interviewed as key informants. Pretested interviewer administered questionnaires were used to collect data from health workers, and key informants. The questionnaires were used to collect information on the knowledge levels among the health workers and key informants on the AFP surveillance system and the attributes of the AFP surveillance system. A checklist was used to assess for the availability of the resources needed for running the AFP surveillance system. A checklist was also used to review AFP notification forms to check for timeliness and completeness. Reports and minutes of AFP surveillance meetings were also reviewed in order to check on the usefulness of the system. The questionnaires and checklists were pretested in the neighbouring Mhondoro Ngezi District at St Michaels Hospital and Turf clinic. Mhondoro Ngezi district health executive members were also interviewed. We checked on the availability of

38


respondents, schedules, and willingness of respondents to answer questions. We also checked on the time needed to administer the questionnaire and checklists. We also checked on the sampling procedure. No adjustments on the questionnaire and sampling procedures were done. Informed written consent was obtained from study respondents. Confidentiality was assured and maintained throughout the study and no names were included. Permission to conduct the study was obtained from the District Medical Officer Sanyati District, Director of Health and Environmental Services Kadoma City, and Health Studies Office Zimbabwe. Data were entered into Epi Info 7, quantitative data was displayed on frequency tables, the measures of central tendency and spread of continuous data were calculated and also contingency tables were used to analyze categorical data. Microsoft Excel TM was used to generate graphs.

3. Results 3.1. Demographic Characteristics of the Respondents A total of 51 health workers were interviewed, 58.8% were females. The median age in services of all the health workers was 5 years (Q1=3; Q3=13). Registered General Nurses18 (35.3%) constituted most of the respondents. A total of 18 health facilities were visited out of 23 in Sanyati district. 3.2. Knowledge on AFP among the health workers All the 51 respondents knew the acronym AFP and 33(65%) of the respondents knew that the targeted age group was under 15years. About 46(90%) of the respondents knew that stool is the specimen of choice, and 34(67%) were aware that 2 stool specimens must be collected and only 28(55%) knew that the 2 specimens must be 24-48hours apart. Only 43(84%) of the respondents knew that the specimens must be stored at +2 to +8 degrees Celsius and 19(37%) knew that specimens must arrive at National Virology Laboratory within 72hours after collection respectively. For the 60day follow up only 16(31%) of the respondents knew about it. Those who managed to answer the questions correctly were 9(18%). 3.3. Knowledge of AFP Surveillance among Health Workers, Sanyati District, 2013 Table 2 shows knowledge level on the AFP surveillance system among health workers in Sanyati District. Those with poor knowledge about the AFP surveillance were 5(9.8%) and most had average knowledge constituting 33(64.7%). 3.4. Usefulness of the AFP Surveillance System Ninety four percent of the respondents perceived that the AFP surveillance system is very useful and 42(82%) of the respondents are using the AFP surveillance data locally. Those that had surveillance meeting at their facilities were 14(28%) and minutes were only produced by 7% of those who had meeting. About 28(72%) of the respondents indicated that AFP surveillance data is being used to plan awareness campaigns for the community. Five percent of the respondents indicated that AFP surveillance data is being used to plan teaching content for health workers. Twenty three percent highlighted that AFP surveillance data is being used to strengthen community based surveillance by village health workers. Thirty one percent of the respondents had some public health actions taken based on AFP surveillance data that were collected. Some of the public health actions taken included; carrying out AFP awareness campaigns (3/15), implementation of active case search (10/15) and Strengthening village health worker performance (3/15) 3.5. Simplicity of the Sanyati AFP Surveillance System Only 8(16%) respondents had ever suspected an AFP case and proceeded to fill the notification form. Of those who suspected and filled the notification form, only 3 took 20-40 minutes to completely take history and completely examine the patient while 5 took between 10-20 minutes to do history and physical examination. Completion of the AFP notification forms, 5 people took less than 10 minutes, 2 took between 10-20 minutes while 1 took 20-40 minutes to fill the form. Seven of the health workers felt the forms were not difficult to fill. Four respondents indicated that they need special training on filling of the AFP notification forms. 3.6. Stability of AFP Surveillance System Sanyati District Table 4 shows the availability of communication system, road network accessibility, availability of AFP case definition and the reporting procedure. Availability of specimen jars, cooler boxes with icepacks, functional dial thermometers and laboratory request forms is also indicated. All the clinics visited were accessible by road and in terms of communication all the clinics have at least one means of communication in the form of a cellphone or radio communication. Case definitions were only displayed by 16 clinics. AFP reporting procedure was not available at all the clinics in Sanyati district.


39

3.7. Representativeness of the Sanyati AFP system All the private institutions in Sanyati district were not participating in the AFP surveillance. Of the 5 private institutions visited indicated that they have all the other items required to do AFP surveillance system such as specimen jars, cooler boxes, phones, however they all indicated that they have not seen the notifications forms. They also indicated that they lack the knowledge on the AFP surveillance system and they are willing to be trained and participate the same way they are doing for other health programmes. Forty two percent said there were hard to reach areas within their catchment areas. Nine percent indicated that they do domiciliary visits by the Environmental Health Technicians. Fifty seven percent in the hard to reach areas do outreach activities, 16(30.4%) utilize village health workers, and 2(4.3%) have established community health committees. 3.8. Sensitivity of the Sanyati AFP Surveillance System In 2006, 2007 and 2012, Sanyati district investigated 4 cases respectively and 2011, 3 cases were investigated. Records for 2007 to 2010 were not available, so cases investigated in those years could not be ascertained. 3.9. Completeness Of the 4 cases that were investigated in 2012, the notification forms were retrieved and the analysis indicated that all the forms were filled well except that all the forms had the laboratory results section not indicated. One form did not indicate when the stool specimens were dispatched, and also the details of the person who dispatched the specimen were not indicated. In 2011, all the 3 forms were completely filled except one form where the date of specimen dispatch and dispatcher were not indicated on the forms. 3.10. Timeliness Of the 4 cases investigated in 2012, 3 cases had stool specimens collected within the required time period and the stool specimen were submitted to National Virology within 72 hours after collection at a temperature of +2 0C to +80C as recommended. One case had 1 stool collected in Sanyati district, and the patient was referred to Harare where the second stool was reported to have been collected but this could not be verified with Harare Hospital. 3.11. Sixty Day Follow Up Two forms were indicating that the second specimen was not collected. From the AFP investigation forms there was need to conduct 60 day follow up. A thorough investigation into the reason why the 60 day follow up was not done proved otherwise. For the 2 cases which were supposed to be investigated, there was a challenge in terms of documentation information. It was noted during investigation that one of the patient died after collection of the first specimen and the other patient was transferred to Harare hospital when the condition deteriorated but all this information was not indicated on the AFP investigation forms. The information was found on the admission notes. However investigations carried out then indicated that there was no needs for 60 day follow up.

4. Discussion Knowledge of health workers on the AFP surveillance system was average. All the respondents knew the acronym AFP but however 65% of the respondents were aware that the targeted age group was under 15years. This is consistent with study findings in 2012 by Chimberengwa et al and Chirau et al where knowledge on the targeted age ground was not known. If the respondents are not aware of the target age group there are chances that some potential cases may be missed by those working at the health facilities and will derail the country from achieving its target (Dube & Gouws, 2009). Ten percent of the respondents did not know that the specimen for AFP was stool; they thought blood was the specimen of choice. Of those who were aware that stool was the specimen of choice only 67% were aware that 2 stool specimens must be collected and only 55% knew that the 2 specimens must be 24-48hours apart. If the stool specimens are not collected within 24-48 hours apart then the specimens will be classified as stool inadequacy. If only one specimen is collected this will also be classified as stool inadequacy because the AFP guidelines in Zimbabwe stipulates that 2 stool specimens collected within 24-48 hours apart must be submitted within 72hours of collection. In terms of specimen submission it was worrying to note that only 37% of the respondents knew that the specimens must arrive at National Virology Laboratory within 72hours after collection respectively. If stool specimens are not submitted within 72hours from time of collection, chances of isolating the virus from the specimens will be reduced. Only 31% of the respondents knew that when there is stool inadequacy 60 day follow up needs to be done. Chirundu et al. in 2005 also noted that most of the respondents were not aware of the 60 day follow up. Follow up of cases that will have been classified as stool inadequacy is very critical in order to achieve the district targets. If 60 day follow up is not done then final classification of the suspected AFP case will not be reached (Chimamise et al., 2009).

40


In terms of the usefulness of the AFP surveillance system in Sanyati about ninety four percent of the respondents think that the AFP surveillance system is very useful. If the system uses believe that that the system is very useful then it likely that the respondents will make use of the AFP surveillance system. Eighty two percent of the respondents were using the AFP surveillance data locally. This very critical because if AFP surveillance data is collected and used locally, it will be for the benefit of the health facility and its community, those that had surveillance meeting at their facilities were 28% and minutes were only produced by 7% of those who had meeting. The proportion of those who had meetings is very low because AFP meetings will enable the surveillance system to function properly and this will also guide future planning (Durrheim et al., 2003). Data being collected is being utilized to plan awareness campaigns for the community (72%); plan teaching content for health workers (5%) and to strengthen community based surveillance by village health workers (23%).Awareness campaigns are critical in the AFP surveillance system because this will ensure that most of the suspected cases are brought to the health facilities soon after onset of paralysis (Valente et al., 1999).Thirty one percent of the respondents had some public health actions taken based on AFP surveillance data that were collected. Some of the public health actions taken included; carrying out AFP awareness campaigns (3/15), implementation of active case search (10/15) and strengthening village health worker performance (3/15) Evidence of active case search was not available at the rural health facilities, however at Kadoma General Hospital, active case search is being done routinely (Ndiaye et al., 2003). Simplicity of the Sanyati AFP surveillance system could not be objectively assessed because only 8(15.7%) had ever suspected an AFP case and proceeded to fill the notification form. However 7 of the health workers felt the forms were not difficult to fill but 4 of the respondents indicated that they need special training on filling of the AFP notification forms. Training on the use of AFP notification form is very critical and needs a standardized training in order to ensure uniformity in the way the forms are filled. Some of the respondents who are involved in assessing paralysis indicated that there is need to revise the forms especially on the terminology that was used because it is not very specific. Stability of the AFP surveillance in Sanyati is good considering that all the health facility had either a functional cellphone or radio communication system. The road network was very poor in all the areas in Sanyati district, some of the clinics could not be accessed due to bad roads. Specimen jars were available at all the clinics and the notification forms were also available. All the private institutions in Sanyati district were not participating in the AFP surveillance. Sanyati district could be missing a lot of possible cases that require investigation considering that there are 5 private institutions and 2 are admitting institutions which must be classified as high priority in terms of AFP surveillance. All the 5 institutions that were visited indicated that they are willing to participate provided they are given the basic training needed for AFP surveillance, they also highlighted that they have some of the required materials for AFP surveillance such as cooler box, specimen jars and they have a functional communication system. Of the 4 cases that were investigated in 2012, the notification forms were retrieved and the analysis indicated that all the forms were filled well except that all the forms had the laboratory results section not indicated. It will be very difficult to give final classification of the suspected cases if the results are not indicated. The district must follow results at day 28 with the National Virology Laboratory. One form did not indicate when the stool specimens were dispatched. If the date of stool dispatch is not indicated it will be virtually impossible to calculate the number of hours from the day the specimen was dispatched to the day it was received by National Virology Laboratory since the specimen must not exceed 72 hours otherwise it will be classified as stool inadequacy. In 2011, all the 3 forms were completely filled except one form where the date of specimen dispatch and dispatcher were not indicated on the forms.

5. Conclusion We therefore conclude that knowledge of health workers on the AFP surveillance in Sanyati was average. The AFP surveillance system in Sanyati district is useful, simple, stable and sensitive but however the system is not representative considering that private institutions are not involved in the AFP surveillance system.

Acknowledgments I would like to express my sincere gratitude to my field supervisor, Mr. D Chirundu for his guidance and to the staff and management at Kadoma City Council, for their unwavering support. I would also want to express my gratitude to staff from the Department of Community Medicine, University of Zimbabwe and Health Studies Office, Zimbabwe for all the help they rendered to me. Many thanks go to health workers in Sanyati District for their support. Last, but not least, I would like to thank all the colleagues who assisted me, and my wife Eugenia Bangure and my son Welldone Bangure for social support throughout the project


41

Competing interests There are no conflicts of interests.

Authors’ contributions Donewell Bangure was responsible for the conception of the problem, design, collection, analysis and interpretation of data and drafting the final article. Daniel Chirundu was responsible for the conception of the problem, design, analysis and interpretation of data and drafting the final article. Notion T.Gombe was responsible for the conception of the problem, design, analysis and interpretation of data and drafting the final article. Lucia Takundwa was responsible for the conception of the problem, design, analysis and interpretation of data and drafting the final article. Mufuta Tshimanga had oversight of all the stages of the research and critically reviewed the final draft for academic content.

References CDC guidelines (polio.pdf) CDC. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP) regarding routine poliovirus vaccination. MMWR2009; 58 (No. 30):829–30 Chimamise, C., Chadambuka, A., Chimusoro, A (2009). Evaluation of the AFP Surveillance System in Mberengwa District; Midlands Province (Unpublished) Chimberengwa, P. T., Masuka, N., Takundwa, L. (2012). Evaluation of the AFP Surveillance System in Gwanda District; Ma tebeleland South, (Unpublished) Chirundu, D., Chihanga, S., Chimusoro, A., Mabaera, B. (2005). Evaluation of the Acute Flaccid Paralysis Surveillance System in Midlands Province, Zimbabwe (Unpublished) Dube, N. M., Tint, K. S., & Gouws, A. M. (2009). Evaluating the Acute Flaccid Paralysis Surveillance System, Mpumalanga Province, SouthAfrica. Durrheim, D. N., Harris, B. N., Speare, R., Billinghurst, K. (2003). The use of hospital-based nurses for the surveillance of potential disease outbreaks, PubMed Central Journal. Ndiaye, S. M., Quick, L., Sandal, O., Niandoul, S. (2003). The value of community participation in disease surveillance: a case study fromNiger,Oxford Journal. Valente, F., Otten, M., Balbina, F., van der Weerdt, R., Chazzi, C., Eriki, P., van Dunnen, J., Okwo Belle, J-M. (1999). Massive outbreak caused by type 3 wild polio virus in Angola. PubMed Central Journal. www.apps.who.int/immunization_monitoring/en/diseases/poliomyelitis/afpextract.cfm accessed 18/2/12 www.cdc.gov/vaccines/pubs/surv-manual/3rd-edition-chpt10_polio.pdf accessed 18/2/12 www.who.int/ihr/Case_Definitions.pdf accessed on 18/2/12

Appendices Table 1. Knowledge of Health Workers on AFP Surveillance System, Sanyati District, 2013 Variable

n=51

Percentage (%)

Knew what the acronym „AFP‟ stands for

51

100

Knew target group for AFP surveillance

33

64.7

Knew four forms are completed for each case investigated

26

59.1

Knew stool specimen is collected for investigations

46

90.2

Knew two stool specimens are collected within 24-48hours apart

28

54.9

Knew two stool specimens are collected

34

66.7

Knew stool should be transported at 2-8 C

43

84.3

Knew stool should arrive at national virology laboratory within 72 hours

19

37.3

Knew that district should mount a concrete response investigation within 14 days

18

35.3

Knew that should expect results from National Virology Laboratory after 28days

9

17.6

Knew about 60 day follow-up

16

31.4

0

42


Table 2. Knowledge Classification of AFP Surveillance, Sanyati District, 2013 Grade

Number (%) n=51

Description of grade

Poor

5(9.8)

< 6 correct responses

Average

33(64.7)

6-8 correct responses

Good

13(25.5)

9-12 correct responses

Table 3. Usefulness of the Sanyati District AFP Surveillance System, 2013 Variable

n=51

Percentage (%)

Think AFP surveillance is useful to the district

48

94.1

AFP Surveillance date that is collected used in any way at the local level

42

82.4

Had AFP surveillance meeting/discussions at the facility

14

28

AFP surveillance minutes seen

1

-

AFP surveillance data used to plan awareness campaigns for the community

28

71.8

AFP surveillance data used to plan teaching content for health workers

2

5.1

AFP surveillance data used to strengthen community based surveillance by village health workers

9

23.1

Public health actions taken based on AFP surveillance data

15

30.6

Carrying out AFP awareness campaigns

3/15

-

Implementation of active case search

10/15

-

Strengthening village health worker performance

3/15

-

Table 4. Stability of the AFP Surveillance System, Sanyati District, Zimbabwe, 2013 System Requirements Communication

Clinics n=18 (%) Working telephone

12

Two-way radio

8

Cellphone network reception

17

Road network accessibility

18

AFP Case definitions displayed

16

AFP Reporting procedure displayed

0

Screw cap specimen jars for stool collection

14

Cooler boxes, with ice packs

18

Laboratory request forms

16

Functional dial thermometers

17

Table 5. AFP Cases Investigated, Sanyati District,Zimbabwe, 2006 to 2012 Year

AFP Cases Investigated

Target

2006

4

1

2007

4

1

2008

Data not available

1

2009

Data not available

1

2010

Data not available

1

2011

3

1

2012

4

1