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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.
[People's perception of diseases: an exploratory study of popular beliefs, attitudes and practices regarding immunizable diseases]
Dhaka, Bangladesh, Worldview International Foundation, 1987 Nov.  p.Researchers interviewed 57 mothers and 27 heads of family in predominantly rural areas about 135km from the capital city of Dhaka, Bangladesh to learn about their perception of diseases. They also talked with 3 traditional healers and 8 influential people in the different locales, e.g., teachers and imams. They learned that each vaccine preventable disease has at least 1 local name rooted in popular beliefs, e.g., all local names for poliomyelitis are associated with an ominous wind. Generally, the local people believe that witches or evil spirits cause all the vaccine preventable diseases. These entities prefer attacking babies, but also are known to afflict women. A preventive measure practiced includes pregnant women never leaving the house in the evening, at noon, or at midnight since these are the times when they are most exposed to evil spirits. There exist 2 traditional healers--fakirs and kabiraj. Fakirs use mystic words with religious chants and perform various healing rituals. The kabiraj sometimes use healing rituals, but also prescribe indigenous medicines. This research provides some useful insights into WHO's Expanded Programme on Immunization in developing communication strategies which build on what people already know. For example, since the local people believe that evil spirits or witches attack the newborn immediately after birth may provide an incentive for early immunization. Since preventing illness and death in newborns is a goal of both modern and traditional medicine, it is likely that the local people are not so concerned with the real cause of illness and will accept any practice that keeps their infant healthy and that fits into their beliefs and perceptions.
Report of the European Region on Immunization Activities. (Global Advisory Group EPI, Alexandria, October 1984). WHO/Expanded Immunization Programme and the European Immunization Targets in the Framework of HFA 2000.
[Unpublished] 1984. Presented at the EPI Global Advisory Group Meeting, Alexandria, Egypt, 21-25 October 1984. 3 p. (EPI/GAG/84/WP.4)Current reported levels of morbidity and mortality from measles, poliomyelitis, diphtheria, tetanus, and tuberculosis in most countries in the European Region are at or near record low levels. However, several factors threaten successful achievement of the Expanded Program on Immunization (EPI) goal of making immunization services available to all the world's children by the year 2000, including changes in public attitudes as diseases pose less of a visible threat, declining acceptance rates for certain immunizations, variations in vaccines included in the EPI, and incomplete information on the incidence of diseases preventable by immunization and on vaccination coverage rates. To launch a more coordinated approach to the EPI goals, a 2nd Conference on Immunization Policies in Europe is scheduled to be held in Czechoslovakia. Its objectives are: 1) to review and analyze the current situation, including achievements and gaps, in immunization programs in individual countries and the European Region as a whole; 2) to determine the necessary actions to eliminate indigenous measles, poliomyelitis, neonatal tetanus, congenital rubella, and diphtheria; 3) to consider appropriate policies regarding the control by immunization of other diseases of public health importance; 4) to strengthen existing or establish additional systems for effective monitoring and surveillance; 5) to formulate actions necessary to improve national vaccine programs in order to achieve national and regional targets; 6) to reinforce the commitment of Member Countries to the goals and activities of the EPI; and 7) to define appropriate activities for the Regional Office for Europe of the World Health Organization to achieve coordinated action.
Geneva, Switzerland, World Health Organization [WHO], 1999. 68 p. (WHO/CDS/99.1; Building a Foundation for Health Development)This paper focuses on the prevention and control of infectious diseases. The WHO reported that infectious diseases caused about 25% of child and young adult mortality as of 1998. In low-income countries, infectious diseases account for 45% of deaths, and are also responsible for 63% of child mortality and 48% premature death. The 6 infectious diseases that caused 90% of the mortality cases include acute respiratory infections (pneumonia and influenza), HIV/AIDS, diarrhea, tuberculosis (TB), malaria, and measles. The obstacles that these diseases pose on health and the economy can be removed through disease prevention and control with cost-effective strategies, such as childhood vaccinations, bednets for malaria, directly observed treatment short-course for TB, integrated management of childhood diseases, antibiotics, and HIV prevention. Due to increased travel, the emergence of diseases and unexpected outbreaks, resistance to antibiotics, and economic development, infectious diseases have become a serious problem both in the developing and industrialized countries.
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.
CURRENT OPINION IN IMMUNOLOGY. 1993 Oct; 5(5):683-6.The author reviews successes and failures in international immunization programs. Although the eradication of smallpox was no small feat, the existence of particularly favorable factors pertinent to its control helped. The Pan American Health Organization proposed in 1985 efforts to eradicate the indigenous transmission of wild-type poliovirus from the Americas by the year 1990. By February 1993, no cases of poliomyelitis had been reported in the Americas for 18 months. This rapid success is remarkable given the comparatively difficult obstacles inherent to the eradication of polio. The goal of eradicating poliovirus was extended to the global level by the World Health Assembly in 1988 for realization by the year 2000. On measles, the World Health Organization Expanded Program on Immunization (EPI) aims to reduce its reported incidence by 90% and mortality by more than 95%, compared with pre-EPI levels, by 1995. More research and maybe a different vaccine are needed, however, given controversy over the use of high-titer vaccine. Mycobacteria which cause leprosy and tuberculosis have long been of minor importance in most developed countries and are controlled with drugs. Elsewhere, more effective vaccines than BCG must be developed and brought to bear against tuberculosis. The author also considers the immunological, delivery, production, efficacy testing, and ethical and social obstacles to developing and implementing HIV vaccines in the Third World. Fertility control vaccines are discussed in closing.
ECONOMIST. 1993 Nov 13; 99-100.The World Health Organization (WHO) eradicated smallpox in 1977. This was the first time that an effective vaccine disseminated through a systematically organized inoculation program had been so successful. In the aftermath, WHO launched the Expanded Program on Immunization (EPI) with the objective of eradicating measles, diphtheria, whooping cough, tetanus, tuberculosis, and polio. These diseases were chosen because all caused major child mortality and effective vaccines existed against each. After 16 years, 80% of the world's children have been immunized and many lives have been saved, but only patchy geographical coverage of immunizations has been achieved and each targeted disease in still with us. In light of this situation, program critics saw the need to take an alternative approach and launched the Children's Vaccine Initiative (CVI) in 1990. EPI concentrated on increasing the effectiveness of bureaucracy to delivery vaccines, but 5 clinic visits in the first 15 months of the baby's life were nonetheless needed for a complete regimen of inoculations against all 6 target diseases. The WHO bureaucracy had trouble incorporating improved vaccines as they were developed and in maintaining the cold chain. The CVI, however, has only minority participation by WHO and the different strategy of focusing upon the development of simpler, more robust vaccines. The CVI is striving to develop a combined vaccine against all 6 diseases which would be affordable, unaffected by changing temperatures, and administered orally in 1 dose shortly after birth. The WHO chief, Nakajima, conceded to the flaws of EPI and agreed to merge the program and its resources with CVI in January, 1994. This move will bring a great deal of program money to CVI. Regarding specific technologies, Virogenetics of Troy, New York, is testing canary-pox-based vaccines on people with the goal of securing a vaccine capable of effectively carrying 7 different antigens. Timed-release capsules are being tested as a means of dealing with the need for repeated doses and it appears that using heavy water to make polio vaccine increases the latter's resistance to heat; researchers are trying to find out why.
ANALES ESPANOLES DE PEDIATRIA. 1992 Jun; 36 Suppl 48:189.New vaccine developments will reflect achievements of the World Health Organization's (WHO) Expanded Programme on Immunization (EPI), as well as resistance from the public toward increasing numbers of vaccines. WHO's EPI program has concentrated on tuberculosis, diphtheria, tetanus, whooping cough, polio, and measles. 35 countries are attempting to control hepatitis B with universal vaccination. Now some countries are also recommending vaccination against Haemophilus influenza, mumps, and rubella. The complexity of multiple injections has prompted new research on acellular vaccines for pertussis, hepatitis A and B, varicella, and malaria. Combined vaccines and new adjuvants are also targets of intense research. Vaccines are a priority, because they are among the most cost-effective of medical interventions.
In: Disease and mortality in Sub-Saharan Africa, edited by Richard G. Feachem, Dean T. Jamison. Oxford, England, Oxford University Press, 1991. 173-89.In Sub-Saharan Africa (SSA), 1% of all children die of neonatal tetanus, 9% of measles, 3% of tuberculosis (TB), and 4% of pertussis. Further, .6% acquire paralytic polio. 20% of the .6% who acquire diphtheria die. Even though vaccination can control these diseases, only 20% of children in SSA receive the complete course of vaccination against the 6 diseases targeted by WHO's Expanded Programme on Immunization (EPI). But high vaccine coverage is not always a cure-all. For example, in the Gambia coverage is high but high mortality levels persist. Of the EPI diseases, measles is the greatest threat since it kills 2 million people annually in developing countries. Measles related mortality is highest in the 9 months following the disease. Even though tetanus is a major cause of death in neonates, tetanus also kills adults such as those that work with the land. Further the tetanus vaccination is effective in adults, but no adult program operates in SSA. Trained midwives reduce neonatal tetanus mortality by 76.6% and vaccination of pregnant mothers with 2 doses of tetanus toxoid reduces mortality 93.3%. Lameness surveys in SSA countries show that, contrary to earlier beliefs, paralytic polio is quite common (range 0.7-13.2). Administration of the oral polio vaccine and improved sanitation are responsible for a real fall in polio cases in the Gambia, the Ivory Coast, and Cameroon. TB was introduced into SSA in the 19th century. It mainly occurs in adults. The estimated life long risk of developing smear positive TB in SSA is 63. The case fatality rate of pertussis in the 1st year of life is high (3.2) and infants do no acquire maternal immunity against it, so the best control measures are early vaccination and identifying secondary cases among young siblings. Of the EPI diseases, scientists know the least about diphtheria in SSA. Its case fatality rate is high (11-38%) yet it is treatable. Primary problems of adequate vaccination coverage for the EPI diseases are managerial problems rather than technological.
BULLETIN OF THE WORLD HEALTH ORGANIZATION. 1991; 69(6):779-89.5-15% of all 3-15 year old children in the world are mentally impaired. In fact, 0.4-1.5% (10-30 million) are severely mentally retarded and an additional 60-80 million children are mildly or moderately mentally retarded. Birth asphyxia and birth trauma account for most cases of mental retardation in developing countries. >1.2 million newborns survive with severe brain damage and an equal number die from moderate or severe birth asphyxia. Other causes of mental retardation can also be prevented or treated such as meningitis or encephalitis associated with measles and pertussis; grave malnutrition during the 1st months of life, especially for infants of low birth weight; hyperbilirubinemia in neonates which occurs frequently in Africa and countries in the Pacific; and iodine deficiency. In addition, iron deficiency may even slow development in infants and young children. Current socioeconomic and demographic changes and a rise in the number of employed mothers may withhold the necessary stimulation for normal development from infants and young children. Primary health care (PHC) interventions can prevent many mental handicaps. For example, PHC involves families and communities who take control of their own care. Besides traditional birth attendants, community health workers, nurse midwives, physicians, and other parents must also participate in prevention efforts. For example, they should be trained in appropriate technologies including the risk approach, home risk card, partograph, mouth to mask or bag and mask resuscitation of the newborn, kick count, and ictometer. WHO has field tested all these techniques. These techniques not only prevent mental handicaps but can also be applied at home, health centers, and day-care centers.
FRONT LINES. 1991 Nov; 16.Indonesia's success in reaching World Health Organization (WHO) universal immunization coverage standards is described as the result of a strong national program with timely, targeted donor support. USAID/Indonesia's Expanded Program for Immunization (EPI) and other USAID bilateral cooperation helped the government of Indonesia in its goal to immunize children against diphtheria, pertussis, tetanus, polio, tuberculosis, and measles by age 1. The initial project was to identify target areas and deliver vaccines against the diseases, strengthen the national immunization organization and infrastructure, and develop the Ministry of Health's capacity to conduct studies and development activities. This EPI project spanned the period 1979-90, and set the stage for continued expansion of Indonesia's immunization program to comply with the full international schedule and range of immunizations of 3 DPT, 3 polio, 1 BCG, and 1 measles inoculation. The number of immunization sites has increased from 55 to include over 5,000 health centers in all provinces, with additional services provided by visiting vaccinators and nurses in most of the 215,000 community-supported integrated health posts. While other contributory factors were at play, program success is at least partially responsible for the 1990 infant mortality rate of 58/1,000 live births compared to 72/1,000 in 1985. Strong national leadership, dedicated health workers and volunteers, and cooperation and funding from UNICEF, the World Bank, Rotary International, and WHO also played crucially positive roles in improving immunization practice in Indonesia.
VACCINE. 1988 Oct; 6(5):393-8.In developing countries, where economic development is lacking and literacy rates are low, priority must be given to primary health care and to the establishmend of sustainable health care delivery systems. The World Health Organization's Expanded Program of Immunization was designed with the goal of immunizing all children against measles, pertussis, tetanus, poliomyelitis, tuberculosis, and diphtheria by 1990. A second function of the immunization program is to establish a health care delivery system. Today 50% of infants receive 3 doses of diptheria/pertussis/tetanus and polio vaccines, and 70% receive at least 1 dose. Measles kills 2 million children every year. The standard strain of attenuated vaccine is given at 9 months, and 1 dose protects 95% of children for life. Tetanus kills 800,000 infants every year. The vaccine must be refrigerated, and 2 doses are essential. Tuberculosis kills 2 million children under 5 every year. The attenuated BCG vaccine should be given at birth, and a single dose confers some protection. Diphtheria is most common among poor, urban children in termperate climates, and 3 doses of toxoid at monthly intervals are recommended. Poliomyelitis paralyzes 250,000 children a year. 4 doses of live attenuated Sabin vaccine are recommended. The vaccine is very sensitive to heat. Other vaccines in use or being developed include yellow fever, meningococcus, Japanese B encephalitis, rubella, hepatitis B, cholera, rotavirus, pneumonococcus, and Haemophilus influezae. 2 problems that confront the delivery of health services, including immunization, are lack of funds and lack of access to susceptible populations. Approaches to the lack of funds problem include fee for service, taxation, beter management of existing resources, reallocation of health resources, and increased funding from donor nations. Approaches to the problem of access include vaccination whenever children come into contact with a health facility for any reason, channeling by members of the community, involvement of traditional healers and birth attendants, outreach services, mass campaigns, pulse technics, and financial incentives.