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

UNICEF

78

58

85

72

0

20

40

60

80

100

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Coverage Measles 1 st dose Global

Source: WHO/UNICEF immunization coverage for 2010

Coverage MCV1 Coverage MCV1 globally and in 47 priority countriesglobally and in 47 priority countries

UNICEF

2000

2005

2010

Number of countries (all countries)

MCV1 coverage 2000 2005 2010

  <70% 37 36 26

  70-79% 27 17 17

  80-89% 44 31 24

  90-99% 84 109 127

Source: WHO/UNICEF immunization coverage for 2010

MCV1 Coverage 2000 – 2010MCV1 Coverage 2000 – 201047 47 Priority CountriesPriority Countries

Human RightsHuman 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 RightsChild 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 dieThe poorest are more likely to die

Indonesia Indonesia Under 5 Mortality Rate by Wealth Quintiles 2002 - 2003Under 5 Mortality Rate by Wealth Quintiles 2002 - 2003

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

Level of under - nutrition in children belonging to the poorest Level of under - nutrition in children belonging to the poorest households has remained stagnant for decadehouseholds has remained stagnant for decade

19.1 million infants not having received MCV1, 2010

CountryCoverage

# 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

Every seventh child not reached

% based on 887 reasons abstracted from 209 relevant articles

28%

7%

44%

21%

Under – vaccinated

55%

6%

12%

27%

Unvaccinated

FamilyCharacter-istics

ImmunizationSystems

ParentalAttitudesAnd Knowledge

% 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

Reasons for under- or un-vaccination

Percentage of children age 12-23 fully immunized

District Level Household Survey 2007-2008

India: Immunization coverage varies significantlyIndia: Immunization coverage varies significantly among different population categoriesamong different population categories

Source: DLHS 2007-08; children surveyed were between 12-23 months

India: Where are the unvaccinated? India: Where are the unvaccinated? Children not vaccinated with DPT3Children not vaccinated with DPT3

FI (DLHS-2)Below 3030 to 5050 to 7070 to 90Above 90

Data not available

FI (DLHS-2)Below 3030 to 5050 to 7070 to 90Above 90

Data not available

Wide intra-state variations

Source: DLHS 2007-08; children surveyed were between 12-23 months

India: Where are the India: Where are the unvaccinated ? unvaccinated ?

District - level percentage of fully immunized childrenDistrict - level percentage of fully immunized children

UNICEF

Poor EducationPoor Education

Mother no TT2+Mother no TT2+

Minority religionMinority religion

RuralRural

No Radio/TVNo Radio/TV

PoorPoor

Source: Swiss Tropical Institute 2010

India – Predictors India – Predictors Only at least one vaccine vs fully immunizedOnly at least one vaccine vs fully immunized

The poorest are more likely not to be immunizedThe poorest are more likely not to be immunized

Greater disparities Greater disparities between provinces between provinces

than rural urbanthan rural urban

UNICEF

- Measles Partnership explores ways to further strengthen routine immunization in 2012

- Plan for critical activities strengthening routine during SIA planning

How to Reach the Under-served How to Reach the Under-served

Possible links between SIAs and RIPossible links between SIAs and RI

UNICEF

Possible links between SIAs and RIPossible links between SIAs and RI

Coordination & accountability for results

Bottom-up Micro-planning

Training

Logistics Management• Cold chain assessment & maintenance

Advocacy and Social Mobilization• Evidence based• Use of community health workers (defaulter tracing)• Health education for caregivers

UNICEF

Possible links between SIAs and RIPossible links between SIAs and RI

AEFI monitoring and management

Surveillance

Monitoring and Evaluation• Supportive supervision• Monitoring charts• Review meetings feeding into new microplans• Rapid assessments

Source: Vijayaraghavan M, Health Policy 2006

Nationwide Measles Vaccination Coverage by Wealth Quintile, Kenya, 2002

Measles campaigns reach the poorest

Source: Vijayaraghavan M, et al. Health Policy 2007, 83: 27-36

• MCV1 coverage has steadily improved from 2000 - 2010

• 19.1 million children remain unreached in 2010

• Focus on under-served populations will have highest impact

ConclusionsConclusions