Enhancing immunization during second year of life by reducing missed opportunities for vaccinations in 46 countries
Introduction
Although estimated global immunization coverage has increased substantially since the start of the Expanded Programme on Immunization (EPI) in 1974, coverage of the third dose of diphtheria-tetanus pertussis vaccine (DTP3) has remained stagnant at around 85% since 2010 [1] and vaccine-preventable diseases remain a major cause of morbidity and mortality worldwide. In 2016, an estimated 6.6 million infants who did receive their first dose of DTP-containing vaccine did not complete the three-dose DTP series [2].
The Global Vaccine Action Plan (GVAP) provides a framework for making vaccines available to all individuals globally and calls on all countries to reach at least 90% national coverage and at least 80% district-level coverage for all vaccines in the country’s national immunization schedule by 2020 [3]. One approach to achieving these goals is to provide vaccination to all eligible persons at every opportunity, including at preventive and curative health service visits. Recommendations for this approach were established by the World Health Organization (WHO) EPI Global Advisory Group in 1983 [4].
More effort is required to increase vaccination coverage. According to recent analyses of demographic health surveys (DHS), ten percent of all children aged below five years in 96 countries did not receive any vaccines and 46% were only partially vaccinated [5]. In addition, a 2014 review conducted in low- and middle-income countries concluded that missed opportunities for vaccination (MOVs) occurred in 32–46% of public health service encounters [6].
Timely vaccination is recommended, but weak immunization and public health systems play a key role in children not receiving vaccines or being incompletely vaccinated. Key factors can include distance to vaccination sites, lack of health worker motivation/diligence, lack of resources, false contraindications and hesitance to open multi-dose vaccine vials [7], [8], [9], [10]. Demand-related factors also play a part, including family characteristics and parental attitudes and knowledge (e.g. educational level and religious beliefs) [11].
Delivering vaccination services during the second year of life (2YL) provides countries with an opportunity to achieve greater population immunity towards reaching GVAP coverage and disease elimination goals [12], [13], [14], [15], including a platform for the introduction of new vaccines and booster doses [13]. Well child visits during the second year of life also provides an opportunity to integrate EPI services with other health and nutrition interventions [14], [15]. This paper uses recent DHSs to examine the magnitude of MOVs among children in their second year of life.
Section snippets
Demographic health surveys (DHS)
Data were selected and analysed from countries where a DHS was conducted between 2010 and 2016 and for which Vitamin A supplementation (VAS) and immunization questions were included [16]. Where countries conducted more than one DHS during this period, data from the most recent survey were analysed, which includes dates of birth for children up to 59 months (5 years) of age. Data eligibility for this study included children aged 12–23 months for which an interviewer could confirm immunization
Results
The analysis included 31 countries from the African region, four from the Americas, four from the Eastern Mediterranean, two from Europe, three from Southeast Asia, and two from the Western Pacific. As per World Bank criteria, four countries were upper-middle income, 19 countries were lower-middle income, and 23 were low income (see Appendix Table 1).
DHS data from 46 countries identified 478,737 children under age five, of which 169,259 met the study eligibility criteria (see methods). Of
Discussion
This analysis highlights that children still failed to receive vaccinations missed in their 1st year of age and by the end of their 2YL, despite having contact with health services during their second year of life.
WHO currently recommends one dose of BCG vaccine, three doses of DPT vaccine, three doses of polio vaccine, and one dose of measles vaccine within the first year of life [19]. WHO also recommends a second dose of measles vaccine between 15 and 18 months of age, a booster dose of DTPCV
Conclusion
Routine screening for immunization status should be carried out on all children who visit health services for any reason. Ideally, eligible persons should be immunized immediately or referred for immunization.
The findings suggest that, despite global progress in immunization, substantial numbers of children fail to benefit from all basic vaccines. Several challenges must be tackled to achieve the GVAP goal of delivering universal access to and use of immunization. These include exploring
Acknowledgements
We thank Shahrouh Sharif, UNICEF, for his support provided in this report.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
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Abbreviations: 2YL, denotes Second Year of Life or 2nd Year of Life.