Routine
Immunization:
The Missed Child
Perspective
Maya van den Ent, PharmD MPH
Edward Hoekstra, MD, MSc
David Brown, DSc, MScPH, MSc
Halima Dao, MD, MSc
Satish Gupta, MD
Coverage MCV1
globally and in 47 priority countries
100
85
80
72
78
60
58
40
20
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
UNICEF
Coverage Measles 1 st dose
Source: WHO/UNICEF immunization coverage for 2010
Global
2009
2010
MCV1 Coverage 2000 – 2010
47 Priority Countries
2000
2005
Number of countries (all countries)
MCV1 coverage
2010UNICEF
Source: WHO/UNICEF immunization coverage for 2010
2000
2005
2010
<70%
37
36
26
70-79%
27
17
17
80-89%
44
31
24
90-99%
84
109
127
Human Rights
The Universal Declaration of
Human Rights:
based on the principle of human
equality;
• everyone has right to equal
access to public services in
his or her country
• everyone has the right to a
standard of living adequate
for the health and well being
of him/her and family,
including food, clothing,
housing, medical care and
social services.
Child Rights….
Convention on the Rights of
the Child:
four core principles:
• non-discrimination
• devotion to the best interests of
the child
• the right to life, survival and
development
• respect for the views of the child.
The poorest are more likely to die
Indonesia
Under 5 Mortality Rate by Wealth Quintiles 2002 - 2003
Level of under - nutrition in children belonging to the poorest
households has remained stagnant for decade
Proportion of children under 5 years who are underweight, by household wealth quintile
Progress for Children: Achieving the MDGs with Equity ; September 2010; NFHS-2005-06
Every seventh child not reached
19.1 million infants not having received MCV1, 2010
India
35%
others
35%
Country
United States
of America
2%
South Africa
2% Afghanistan
2%
Ethiopia
2%
Indonesia
3%
Nigeria
9%
Pakistan Uganda
3%
3%
DR Congo
4%
Cover
age
# Infants no
MCV1 (routine)
India
74
6,709,000
Nigeria
71
1,668,000
DR Congo
68
815,000
Uganda
55
630,000
Pakistan
86
619,000
Indonesia
89
468,000
Ethiopia
81
463,000
Afghanistan
62
458,000
South Africa
65
352,000
USA
92
342,000
Reasons for under- or un-vaccination
Under – vaccinated
Unvaccinated
21%
27%
28%
Family Characteristics
Parental
Immunization
System
7%
Immunization
Systems
44%
% based on 887 reasons abstracted from 209 relevant articles
Family
Characteristics
Attitudes
55%
Communication
and Information
And
Knowledge
Parental Attitudes and Knowledge
12%
6%
% based on 33 reasons abstracted from 12 articles on unvaccinated children
Under vaccinated: Infants received at least one vaccine, but no DTP3
Un-vaccinated: Infants received no vaccine at all
India: Immunization coverage varies significantly
among different population categories
Percentage of children age 12-23 fully immunized
73
37
63
63
53
50
46
36
Urban
Rural
Others
Scheduled Scheduled
Castes
Tribes
District Level Household Survey 2007-2008
Richest
Qunitle
Poorest
Quintile
India: Where are the unvaccinated?
Children not vaccinated with DPT3
Source: DLHS 2007-08; children surveyed were between 12-23 months
India: Where are the unvaccinated ?
District - level percentage of fully immunized children
Data not available
FI (DLHS-2)
Below 30
30 to 50
50 to 70
70 to 90
Above 90
Data not available
FI (DLHS-2)
Below 30
30 to 50
50 to 70
70 to 90
Above 90
Wide intra-state variations
Source: DLHS 2007-08; children surveyed were between 12-23 months
India – Predictors
Only at least one vaccine vs fully immunized
Poor Education
Mother no TT2+
Minority religion
Rural
No Radio/TV
Poor
UNICEF
Source: Swiss Tropical
Institute 2010
The poorest are more likely not to be immunized
DR Congo
Disparities in Vaccination Coverage
Measles
(MCV1)
Province
DTP3
Province
BCG
Province
Measles
(MCV1)
Rural vs Urban
DTP3
Rural vs Urban
BCG
Between lowest Provincial and highest Provincial coverage
Between rural and urban coverage
Rural vs Urban
Greater disparities
between provinces
than rural urban
0
10
20
30
40
50
Coverage Rate (%)
Source: MICS 2010
60
70
80
Lowest
90
100
Highest
How to Reach the Under-served
Possible links between SIAs and RI
- Measles Partnership explores ways to further
strengthen routine immunization in 2012
- Plan for critical activities strengthening
routine during SIA planning
UNICEF
Possible links between SIAs and RI
Coordination & accountability for results
Bottom-up Micro-planning
Training
Logistics Management
• Cold chain assessment & maintenance
Advocacy and Social Mobilization
•
•
•
UNICEF
Evidence based
Use of community health workers (defaulter tracing)
Health education for caregivers
Possible links between SIAs and RI
AEFI monitoring and management
Surveillance
Monitoring and Evaluation
•
•
•
•
UNICEF
Supportive supervision
Monitoring charts
Review meetings feeding into new microplans
Rapid assessments
Measles campaigns reach the poorest
Nationwide Measles Vaccination Coverage by Wealth Quintile, Kenya, 2002
Source: Vijayaraghavan M, et al. Health Policy 2007, 83: 27-36
Source: Vijayaraghavan M, Health Policy 2006
Conclusions
• MCV1 coverage has
steadily improved
from 2000 - 2010
• 19.1 million children
remain unreached in
2010
• Focus on underserved populations
will have highest
impact