ReviewReasons related to non-vaccination and under-vaccination of children in low and middle income countries: Findings from a systematic review of the published literature, 1999–2009
Introduction
Immunization is one of the most successful and cost-effective public health interventions for reducing infant and child morbidity and mortality globally [1]. Although the World Health Organization estimated that immunizations saved approximately 2.5 million lives in 2006, an estimated 1.4 million children died from vaccine preventable diseases (measles, Haemophilus influenzae type b, pertussis, tetanus, yellow fever, and poliomyelitis) during the same year because they were not fully vaccinated [2].
The Expanded Programme on Immunization (EPI) was launched in 1974 to provide free routine vaccinations to children. Operated by Ministries of Health with technical support from the World Health Organization, EPI has contributed to improvements in coverage towards the global goal of ≥90% of children in each member country receiving the third dose of DTP vaccine (DTP3) and coverage of ≥80% in all districts by 2010 [3]. Despite health worker training, targeted outreach services, and new strategies such as the Reaching Every District (RED) approach [4], the percent of children fully vaccinated has not reached these targets. Although global DTP3 coverage reached 82% in 2008, only 42 (27%) of the 157 WHO member states defined as low or middle income in 2006 had DTP3 coverage greater than 80% in all districts [2].
In 2008, the World Health Organization (WHO) Strategic Advisory Group of Experts on Immunization (SAGE) requested information on “the epidemiology of the non-vaccination” and under-vaccination of children with the basic routine immunizations in order to formulate strategies to decrease the number of children who are unvaccinated or only partially vaccinated [5]. Information was needed particularly for low and middle income countries, where vaccination coverage has been historically inadequate to prevent transmission of vaccine preventable diseases [1]. We conducted a systematic review of the peer-reviewed literature published between 1999 and 2009 with the objective to aggregate and summarize reasons that children in low and middle income countries remain under-vaccinated or unvaccinated with the EPI recommended vaccinations. We did not attempt to examine the merits of universal vaccination, assess country specific health systems, or quantify the impact of each reason on the number of unvaccinated or partially vaccinated children. Review findings can contribute to the development of local, national, and regional interventions to improve coverage of all EPI vaccinations. Country-level fact sheets containing relevant information on reasons for under-vaccination were developed and provided to Ministries of Health. The SAGE request also included a review of the grey literature (unpublished reports, meeting documents, and articles from non-peer reviewed journals) and an analysis of the Demographic and Health Survey (DHS) data. Results from these projects are reported separately [6], [7].
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Literature database search
Eight different medical, behavioural and social science literature databases were searched for relevant articles published from January 1, 1999 to March 31, 2009. These included Medline® (National Library of Medicine) and seven non-Medline databases: Embase® (Excerpta Medica Database, Elsevier), CSA Sociological Abstracts (ProQuest), Social Services Abstracts, Educational Resources Information Center (ERIC), Cochrane, Web of Science, and CINALH® (Cumulative Index to Nursing and Allied Health
Description of articles
The literature database search resulted in 9,480 articles from the Medline® database and 6,617 articles from the seven non-Medline databases (Table 1). The initial review of titles and abstracts identified 620 relevant articles (including articles received from IDRC); of these, 202 articles were determined to be highly relevant and of high quality following full review. Of 418 excluded articles, 180 (43%) were deemed not relevant, 108 (26%) were duplicates, 59 (14%) were not published in a
Discussion
A number of themes related to under-vaccination and non-vaccination emerged in this review, including weaknesses in the immunization delivery system, problems with communication or information delivery, family characteristics, and parental knowledge regarding vaccination. The multiplicity of causes that we identified suggests the complex nature of this issue, and calls for a multi-faceted approach to reaching under-vaccinated and unvaccinated children. While some of these factors, such as the
Conclusions
The reasons for under-vaccination and non-vaccination are multi-factorial, and while no single intervention can address all identified barriers to timely childhood vaccination, some problems are more easily remedied than others. This review identified several patterns of reasons related to under-vaccination and non-vaccination of children in low and middle income countries. Many of those associated with under-vaccination were related to immunization system factors and access to services, and
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The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy, or views of the World Health Organization.