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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.
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.
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.
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.
[Unpublished] 1988. Presented at the 13th World Conference on Health Education, Houston, Texas, August 28 - September 2, 1988. 60 p.This study is the report of a 1986 baseline survey, guided by the World Health Organization's "Guidelines for a Sample Survey of Diarrheal Diseases Morbidity, Mortality, and Treatment Rate." The survey method was the Expanded Program on Immunization 30 cluster 2-stage method. Baseline data were also gathered on the status of immunization against diphtheria, tetanus, whooping cough, poliomyelitis, measles, and tuberculosis. Primary health care services in Bahrain are generally good. The archipelago of 670 sq km has a population of 417,210 including 55,000 children under 5. There are 18 health centers and 480 physicians or 1 physician for every 860 people. All inhabitants of a catchment area live within 5 km of a health center, and medical care is free. Diarrhea is due to a number of different organisms, including typhoid, paratyphoid, salmonellosis, Escherichia coli, rotaviruses, and giardiasis, but there has been no cholera in Bahrain since 1979. The national diarrheal diseases control program, drafted by the World Health Organization in 1985, emphasized the use of oral rehydration therapy, breast feeding, and feeding during diarrhea. No vaccinations are compulsory in Bahrain, but immunization coverage has been reported annually since 1981, and vaccinations are in line with the World Health Organization's criteria. Diphtheria-Typhoid-Paratyphoid vaccinations were 1st given in Bahrain in 1957; polio vaccination began in 1958 with Salk vaccine and in 1962 with the Sabin vaccine. Measles vaccination began in 1974. BCG vaccination has been given to children entering school since 1972. All health centers in the country offer vaccination services. Vaccines are stored under refrigeration, and the central supply is at the Public Health Directorate. Adverse effects of vaccinations are monitored. The 1986 diarrheal diseases survey, using the 30 cluster method, looked at a sample of 4114 children under 5 from 2515 households. 378 (9.2%) of the children suffered from diarrhea, and 200 (52.9%) were treated with oral rehydration salts. The under-5 diarrheal mortality rate was .97/1000. The estimated number of episodes of diarrhea per child per year is 2.4, with a high of 8.7 episodes in the Northern Region and a low of 1.2 episodes in the Muharraq Region. Vaccination coverage of children under 2 for other diseases was found to be 96.5% for diphtheria, paratyphoid, and typhoid; 95% for polio; 82.5% for measles; and 59.8% for the trivalent mumps, measles and rubella vaccine. 96.4% of all vaccinations were given in government hospitals. 98.7% of mothers have been examined during pregnancy, and 98.9% of all deliveries are in hospitals. It is recommended that a health education campaign be concentrated on diarrhea, breast feeding, feeding during diarrhea, and hygiene; that both medical staff and mothers be trained in the use of oral rehydration salts; that they should also be informed of the adverse effects of treating diarrhea with antibiotics; that a system for reporting cases of diarrhea be developed; that health education campaigns emphasize the importance of receiving booster doses of vaccines and of vaccination against measles; that staff at health centers adjust their schedules so as to be available for immunizations as needed; and that this survey be repeated every 2 years.
INFECTION CONTROL. 1984 Nov; 5(11):538-41.In 1978 the Ministry of Health and Social Welfare (MHSW) of Liberia launched the Expanded Program on Immunization (EPI) with the 5-year objective of establishing an 80% reduction in child mortality and morbidity from measles, polio, diphtheria, neonatal tetanus, pertussis, and tuberculosis. The program at first adopted a strategy of using 15 mobile units in 11 operational zones to deliver vaccinations throughout the country. However, by 1980, despite support from the Baptist World Alliance, the UN International Children's Emergency Fund (UNICEF), and the World Health Organization (WHO), it became evident that the mobile strategy was neither economically feasible nor practical. Therefore, with support from the US Agency for International Development (USAID), the EPI shifted to a strategy of integrating immunization activities into the existing network of state health facilities. After 5 years, in 1982, the Program was evaluated by a team from the MHSW, WHO, USAID, and the Centers for Disease Control. The evaluating team felt that the EPI's strategy was good, but its goals were not being achieved due to deficiencies in funding, clinic supervision, and rural community outreach, as well as shortages of kerosene and spare parts needs to keep the essential refrigerators in operating condition. Measles remains endemic; in the capital, Monrovia, only 9% of the children have been vaccinated against it. Immunization coverage is particularly low in the capital the countries. Other reasons for low vaccination coverage in Liberia are lack of community awareness of existing facilities and the importance of vaccination and lack of coordination at the community level to use the existing facilities efficiently. International assistance is still needed, especially to develop heat-stable vaccines, so that maintenance of refrigerators will not be necessary.
WORLD HEALTH STATISTICS QUARTERLY. RAPPORT TRIMESTRIEL DE STATISTIQUES SANITAIRES MONDIALES. 1988; 41(1):19-25.Routine surveillance of the incidence of vaccine-preventable diseases has not proved sensitive enough to demonstrate the impact of the Expanded Program on Immunization (EPI) in many countries. In order to document progress since the start of the EPI in 1979, data are needed for several years prior to that. In most developing countries these can be found only in major cities or large hospitals. Therefore a system of sentinel surveillance, the Local Area Monitoring Project (LAM), is being set up in selected institutions in the major cities of the developing world. The primary goal of the LAM project is to provide disease-incidence data of sufficient quality to evaluate more fully the global impact of the EPI on the 6 target diseases--diptheria, pertusis, tetanus, poliomyelitis, measles, and tuberculosis. The goal is to include the major city of each of the 25 largest developing countries, with a total population of 115 million. These 25 countries together account for 85% of all births in the developing world. The program and coverage information is used to assess the impact of individual EPI programs on disease trends. Preliminary analysis of the 12 cities with the best data suggests that the impact of the EPI on the incidence of the target diseases has been greater than previously shown by the routine system. The LAM information is useful for global and regional analysis of program impact, but for the countries themselves its utility may be even greater. It is hoped that the project will help to improve a country's surveillance system by encouraging the use of sentinel reporting as a means of supplementing routine data. The information on the impact of the EPI may further increase political and public support for a program. (Summaries in ENG, FRE)