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Routine vaccination coverage in low- and middle-income countries: further arguments for accelerating support to child vaccination services.
Global Health Action. 2013; 6:20343.BACKGROUND AND OBJECTIVE: The Expanded Programme on Immunization was introduced by the World Health Organization (WHO) in all countries during the 1970s. Currently, this effective public health intervention is still not accessible to all. This study evaluates the change in routine vaccination coverage over time based on survey data and compares it to estimations by the WHO and United Nations Children's Fund (UNICEF). DESIGN: Data of vaccination coverage of children less than 5 years of age was extracted from Demographic and Health Surveys (DHS) conducted in 71 low- and middle-income countries during 1986-2009. Overall trends for vaccination coverage of tuberculosis, diphtheria, tetanus, pertussis, polio and measles were analysed and compared to WHO and UNICEF estimates. RESULTS: From 1986 to 2009, the annual average increase in vaccination coverage of the studied diseases ranged between 1.53 and 1.96% units according to DHS data. Vaccination coverage of diphtheria, tetanus, pertussis, polio and measles was all under 80% in 2009. Non-significant differences in coverage were found between DHS data and WHO and UNICEF estimates. CONCLUSIONS: The coverage of routine vaccinations in low- and middle-income countries may be lower than that previously reported. Hence, it is important to maintain and increase current vaccination levels.
Bulletin of the World Health Organization. 2007 Jun; 85(6):449-457.The objective was to assess the progress made towards meeting the goals of the African Regional Strategic Plan of the Expanded Programme on Immunization between 2001 and 2005. We reviewed data from national infant immunization programmes in the 46 countries of WHO's African Region, reviewed the literature and analysed existing data sources. We carried out face-to-face and telephone interviews with relevant staff members at regional and subregional levels. The African Region fell short of the target for 80% of countries to achieve at least 80% immunization coverage by 2005. However, diphtheria-tetanus-pertussis-3 coverage increased by 15%, from 54% in 2000 to 69% in 2004. As a result, we estimate that the number of nonimmunized children declined from 1.4 million in 2002 to 900 000 in 2004. In 2004, four of seven countries with endemic or re-established wild polio virus had coverage of 50% or less, and some neighbouring countries at high risk of importation did not meet the 80% vaccination target. Reported measles cases dropped from 520 000 in 2000 to 316 000 in 2005, and mortality was reduced by approximately 60% when compared to 1999 baseline levels. A network of measles and yellow fever laboratories had been established in 29 countries by July 2005. Rates of immunization coverage are improving dramatically in the WHO African Region. The huge increases in spending on immunization and the related improvements in programme performance are linked predominantly to increases in donor funding. (author's)
Adverse events after immunisation with aluminium-containing DTP vaccines: systematic review of the evidence.
Lancet Infectious Diseases. 2004 Feb 1; 4(2):84-90.We have reviewed evidence of adverse events after exposure to aluminium-containing vaccines against diphtheria, tetanus, and pertussis (DTP), alone or in combination, compared with identical vaccines, either without aluminium or containing aluminium in different concentrations. The study is a systematic review with metaanalysis. We searched the Cochrane Vaccines Field Register, the Cochrane Library, Medline, Embase, Biological Abstracts, Science Citation Index, and the Vaccine Adverse Event Reporting System website for relevant studies. Reference lists of retrieved articles were scanned for further studies. We included randomised and semi-randomised trials and comparative cohort studies if the report gave sufficient information for us to extract aluminium concentration, vaccine composition, and safety outcomes. Two reviewers extracted data in a standard way from all included studies and assessed the methodological quality of the studies. We identified 35 reports of studies and included three randomised trials, four semi-randomised trials, and one cohort study. We did a meta-analysis of data from five studies around two main comparisons (vaccines containing aluminium hydroxide vs no adjuvant in children aged up to 18 months and vaccines containing different types of aluminium vs no adjuvants in children aged 10–16 years). In young children, vaccines with aluminium hydroxide caused significantly more erythema and induration than plain vaccines (odds ratio 1·87 [95% CI 1·57–2·24]) and significantly fewer reactions of all types (0·21 [0·15–0·28]). The frequencies of local reactions of all types, collapse or convulsions, and persistent crying or screaming did not differ between the two cohorts of the trials. In older children, there was no association between exposure to aluminiumcontaining vaccines and onset of (local) induration, swelling, or a raised temperature, but there was an association with local pain lasting up to 14 days (2·05 [1·25–3·38]). We found no evidence that aluminium salts in vaccines cause any serious or long-lasting adverse events. Despite a lack of good-quality evidence we do not recommend that any further research on this topic is undertaken. (excerpt)
Copenhagen, Denmark, WHO, Regional Office for Europe, 1996.  p. (EUR/ICP/CMDS 96 06 01 03)The WHO/UN Children's Fund Strategy for diphtheria control includes three main recommendations: 1) mass immunization; 2) early diagnosis and proper treatment of cases; and 3) management of close contacts by the use of antibiotics. Whereas the first two recommendations have been implemented in all New Independent States having epidemic diphtheria, in some countries there is a controversial discussion regarding the use of antibiotics for close contacts. Therefore, WHO, with assistance of Centers for Disease Control and Prevention and US Agency for International Development/Basic Support for Institutionalizing Child Survival has drafted guidelines regarding the antibiotic prophylaxis of contacts of diphtheria cases based on international experience. The guidelines include reprints of publications demonstrating the success of this strategy. (author's)
BMJ. British Medical Journal. 2001 Feb 10; 322(7282):361.The paper by Kristen et al. challenges the safety of diphtheria, tetanus, and pertussis vaccine. The Global Advisory Committee on Vaccine Safety of the WHO has closely considered the reported findings and conclusions of the paper and found that numerous serious deficiencies in the paper did not allow it to reach the same definitive conclusions reached by the authors. In particular, it found that the reported observations are incomplete and do not tally, and no systematic effort has been made to address the likelihood of bias introduced by the method of data collection. In addition, the probability of the results being distorted by confounding factors has not been adequately addressed. Another point of criticism was that the analysis was data-driven and not based on prior generation of a hypothesis. It is important that the safety and impact of current immunization schedules be studied, particularly in high-risk situations. It is emphasized, however, that no change is warranted in current policy with regard to immunization practices, including BCG, diphtheria, tetanus, and pertussis, oral polio, and measles vaccines in national immunization schedules.
Bulletin of the World Health Organization. 2000; 78(8):1062-3.According to the report of the UN International Children's Emergency Fund (UNICEF), worldwide diphtheria, pertussis, tetanus, and poliomyelitis vaccination programs are still failing to reach millions of children in the developing world, particularly in Africa. It is noted that in developing countries 370,000 children below 5 years of age die from whooping cough and another 50,000 die from tuberculosis every year. Moreover, more than half of the infants born are unprotected against tetanus and 200,000 die from the disease. The report reveals that a large part of the problem is related to inadequate funding and the high cost of initiating broad-based programs. While the reports widely credits UNICEF with promoting vaccination efforts in developing countries, it also points to several private and public-private efforts, including the commitment of US$750 by the Bill and Melinda Gates Foundation for the development of the Global Alliance for Vaccines and Immunization.
WORLD HEALTH FORUM. 1998; 19(2):162-73.In 1796, English country doctor Edward Jenner demonstrated that scratching cowpox virus onto the skin produced immunity against smallpox. Following this scientific demonstration, the practice of vaccination gradually became widespread during the 19th century, and began to be applied to other infections. However, the use of vaccines was largely confined to the industrialized countries. Immunization played no significant role in the World Health Organization's (WHO) early activities. In 1974, however, WHO launched its Expanded Program on Immunization (EPI) with the goal of immunizing all of the world's children against diphtheria, pertussis, tetanus, measles, poliomyelitis, and tuberculosis. At that time, only less than 5% of all children had been immunized against the diseases. The word "expanded" referred to the addition of measles and poliomyelitis to the vaccines then being used in the immunization program. Now, 80% of the world's children receive such protection against childhood diseases during their first year of life, coverage could reach 90% by 2000, vaccines are becoming more effective, and vaccines against additional diseases are being added to the program.
Deaths, severe reactions after DTP not due to vaccine, says study team. Adverse reactions in Kazakhstan.
VACCINE AND IMMUNIZATION NEWS. 1996 Jun; (1):1-2.Kazakhstan's ministry of health recently notified UNICEF of the deaths of 4 children under age 6 months which occurred within 24 hours to 6 days following immunization with diphtheria/pertussis/tetanus (DPT) vaccine. Thinking that the vaccine may have caused the deaths, the ministry was considering halting its national children's immunization program. Within 1 week of the report of the third death, a joint WHO-UNICEF team of experts arrived in Kazakhstan to investigate. Although the team strongly suspected that the deaths were due to defective vaccine, vaccination was quickly ruled out as the cause of death due to a number of reasons. The WHO-UNICEF team instead believes that failure to observe proper immunization procedure may have caused the deaths. Visits to 2 health centers in which 2 of the children were immunized produced no evidence in support of this latter hypothesis. Kazakhstan officials also reject poor immunization practices as a possible cause. Kazakhstan's ministry of health plans to investigate all of the cases, while WHO and UNICEF have recommended a review of the national immunization program and are waiting to see if the recommendation is followed up.
Geneva, Switzerland, WHO, EPI, 1997. viii, 190 p. (WHO/EPI/GEN/97.02)The Expanded Program on Immunization Information System (EIS) collects, compiles, and distributes statistics on immunization coverage and communicable disease incidence. This document, based on reports submitted to the World Health Organization by Member States, contains three sections: 1) regional and global summaries for 1980-96 of immunization coverage with Bacille Calmette Guerin vaccine, the third dose of diphtheria toxoid-tetanus toxoid-pertussis vaccine, measles vaccine, the third dose of oral polio vaccine, the second and subsequent doses of tetanus toxoid vaccine, and yellow fever vaccine; 2) featured issues, including immunization program performance and countries in greatest need of improved performance; and 3) a reference section with country profiles and disease incidence and coverage tables. The country profiles also include data on population, newborns, child survival, the female literacy rate, and the per capita gross national product.
Arlington, Virginia, Partnership for Child Health Care, 1995. iii, 29 p. (BASICS Trip Report; BASICS Technical Directive: 000 NS 01 021; USAID Contract No. HRN-6006-C-00-3031-00)A diphtheria outbreak in the Caucuses necessitated a BASICS (Basic Support for Institutionalizing Child Survival) consultant to go to Armenia, Azerbaijan, and Georgia, during July 14-August 5, 1995, to determine the status of planning and preparations for mass immunization campaigns and disease control efforts. The campaigns are expected to take place during August-November 1995. There is enough funding to deliver supplies, oversee the planning and implementation of the campaigns at the district level, and to monitor the campaigns. UNICEF is securing sufficient antibiotics and diphtheria antitoxin. Political unrest plagues certain areas of all three countries. None of the countries have the resources to provide adequate health care. Health workers cannot be paid a living wage. None of the Ministries of Health (MOHs) are equipped to deliver and oversee immunization activities. UNICEF is providing new cold chain equipment. Yet, most health workers have not received training on vaccine storage requirements. They do not monitor refrigerator temperatures. UNICEF needs to provide technical assistance in monitoring and maintenance of the cold chain in all three countries. MOHs are in the process of improving management but trained managers and effective supervision will not be ready for a long time. Nongovernmental organizations (NGOs) can help with logistics, monitoring, social mobilization, local organization, and delivering immunizations. NGOs' assistance in coordinating resources will ease UNICEF's burden. Since December 1994, vaccines and supplies have been available in Ajara, Georgia, yet no mass immunization campaign has been implemented. In July, there were 27 cases of diphtheria in Ajara. UNICEF is trying to motivate the MOHs in Ajara and Tbilisi to immediately begin immunization and other control measures. BASICS could provide technical assistance with planning strategies for social mobilization and planning, implementation, and data analysis for post-campaign evaluations and coverage surveys.
Arlington, Virginia, Partnership for Child Health Care, 1994. , 7,  p. (BASICS Trip Report; BASICS Technical Directive: 000 NS 01 001; USAID Contract No. HRN-6006-C-00-3031-00)In December 1994 in Berlin, Germany, WHO and UNICEF sponsored a meeting on diphtheria control strategy for the Newly Independent States (NIS). The participants prepared a proposed strategy to be elaborated on and endorsed by ministries of health (MOHs) of the NIS and donor agencies at 2 follow-up meetings scheduled for January 1995. The NIS is experiencing a diphtheria epidemic. The epidemic is starting to stabilize only in the Ukraine. Children comprise 40% of cases. Diphtheria has become firmly established in all age groups and throughout entire countries, so past immunization strategies (i.e., 3 doses of diphtheria toxoid-containing vaccine [Td] for just high risk groups) cannot curb the epidemic. Now as many people as possible must receive 1 dose of such a vaccine. Some high risk age groups should receive additional doses. A group at very high risk of diphtheria is school-aged children. Last year it was estimated that the Ukraine needed 22 million doses of Td for mass immunization, but it now needs 81 million doses of Td. UNICEF will provide 4 doses of DPT (diphtheria, pertussis, tetanus toxoid) vaccine as part of the standard primary series and 1 booster dose of diphtheria-tetanus vaccine (pediatric formulation) at school entry. Manufacturers are not responding to requests for production of additional quantities of antitoxin by the spring, thereby prolonging the chronic global shortage of antitoxin. The meeting was productive in developing a technically sound strategy, but more attention is needed to produce political interest/will and to mobilize resources. In addition to WHO talking to MOHs, more media coverage and social mobilization are needed within each NIS. During the next few months, WHO and UNICEF will determine whether a pledging session of potential donors is needed. The International Federation of Red Cross is donating $2 million for diphtheria control in the Ukraine.