Pakistan's expanded programme on immunization: An overview in the context of polio eradication and strategies for improving coverage

Since its inception in 1978, Pakistan's Expanded Programme on Immunization (EPI) has contributed significantly towards child health and survival in Pakistan. However, the WHO-estimated immunization coverage of 88% for 3 doses of Diptheria-Tetanus-Pertussis vaccine in Pakistan is likely an over-estimate. Many goals, such as polio, measles and neonatal tetanus elimination have not been met. Pakistan reported more cases of poliomyelits in 2011 than any other country globally, threatening the Global Polio Eradication Initiative. Although the number of polio cases decreased to 58 in 2012 through better organized supplementary immunization campaigns, country-wide measles outbreaks with over 15,000 cases and several hundred deaths in 2012–13 underscore sub-optimal EPI performance in delivering routine immunizations. There are striking inequities in immunization coverage between different parts of the country. Barriers to universal immunization coverage include programmatic dysfunction at lower tiers of the program, socioeconomic inequities in access to services, low population demand, poor security, and social resistance to vaccines among population sub-groups. Recent conflicts and large-scale natural disasters have severely stressed the already constrained resources of the national EPI. Immunization programs remain low priority for provincial and many district governments in the country. The recent decision to devolve the national health ministry to the provinces has had immediate adverse consequences. Mitigation strategies aimed at rapidly improving routine immunization coverage should include improving the infrastructure and management capacity for vaccine delivery at district levels and increasing the demand for vaccines at the population level. Accurate vaccine coverage estimates at district/sub-district level and local accountability of district government officials are critical to improving performance and eradicating polio in Pakistan.     

Spatial and socio-demographic predictors of time-to-immunization in a rural area in Kenya: Is equity attainable?

We conducted a vaccine coverage survey in Kilifi District, Kenya in order to identify predictors of childhood immunization. We calculated travel time to vaccine clinics and examined its relationship to immunization coverage and timeliness among the 2169 enrolled children (median age: 12.5 months). 86% had vaccine cards available, >95% had received three doses of DTP-HepB-Hib and polio vaccines and 88% of measles. Travel time did not affect vaccination coverage or timeliness. The Kenyan EPI reaches nearly all children in Kilifi and delays in vaccination are few, suggesting that vaccines will have maximal impact on child morbidity and mortality.     

The impact of the national polio immunization campaign on levels and equity in immunization coverage: evidence from rural North India

Few studies have investigated the impact of immunization campaigns conducted under the global polio eradication program on sustainability of polio vaccination coverage, on coverage of non-polio vaccines (administered under Expanded Program on Immunization (EPI)), and on changes in social inequities in immunization coverage. This study proposes to fill the gaps in the evidence by investigating the impact of a polio immunization campaign launched in India in 1995. The study uses a before-and-after study design using representative samples from rural areas of four North Indian states. The National Family Health Survey I (NFHS I) and NFHS II, conducted in 1992-93 and 1998-99 respectively, were used as pre- and post-intervention data. Using pooled data from both the surveys, multivariate logistic regression models with interaction terms were used to investigate the changes in social inequities.During the study period, a greater increase was observed in the coverage of first dose of polio compared to three doses of polio. Moderate improvements in at least one dose of non-polio EPI vaccinations, and no improvements in complete immunization against non-polio EPI diseases were observed. The polio campaign was successful, to some extent, in reducing gender-, caste- and wealth-based inequities, but had no impact on religion- or residence-based inequities. Social inequities in non-polio EPI vaccinations did not reduce during the study period. Significant dropouts between first and third dose of polio raise concerns of sustainability of immunization coverage under a campaign approach. Similarly, little evidence to support synergy between polio campaign and non-polio EPI vaccinations raises questions about the effects of polio campaign on routine health system's functions. However, moderate success of the polio campaign in reducing social inequities in polio coverage may offer valuable insights into the routine health systems for addressing persistent social inequities in access to health care.     

A ten-year experience in control of poliomyelitis through a combination of live and killed vaccines in two developing areas.

We describe a successful program of poliomyelitis control using a combination of killed and live polio vaccines over a 10-year period in two developing areas, the West Bank and Gaza, adjacent to a relatively developed country, Israel. During the 1970s, immunization using live trivalent oral polio vaccine (OPV) in these areas covered more than 90 percent of the infant population. Nevertheless, the incidence of paralytic polio continued to be high, with many cases occurring in fully or partially immunized persons. It was thought that this could be due to interference with OPV take by other enteroviruses present in the environment due to poor sanitary conditions in these areas. A new policy combining five doses of OPV with two doses of inactivated polio vaccine (IPV) was adopted and implemented in 1978. In the 10 years since then, immunization coverage of infants increased to an estimated 95 percent and paralytic poliomyelitis has been controlled, despite exposure to wild poliovirus from neighboring countries including an outbreak in Israel in 1988. This experience suggests that wide coverage using the combination of IPV and OPV is an effective vaccination policy that may make eradication of polio possible even in developing areas.     

Poliomyelitis and the control programme

Poliomyelitis, an acute infectious disease which chiefly affects the central nervous system, is included in the list of 20 communicable diseases which are to be reported monthly by all institutions to the State Bureau of Health Intelligence for onward transmission to India's Central Bureau of Health Intelligence (CBHI). The reported number of 17,441 cases of poliomyelitis (annual average) since 1974 fail to reflect the magnitude of the problem in India. Directorate General of Health Services (DHGS) in collaboration with the State health authorities organized sample lameness surveys of children 5-9 years in the community during 1981-82. Poliomyelitis was found to be the major cause of lameness in children 5-9 years (64.5%). Data on admission of poliomyelitis cases from selected hospital in metropolitan cities were collected. All the hospitals reported maximum number of polio cases (more than 78%) below the age of 2 years. This data reinforce the importance of improving vaccination coverage in the age group most affected. High incidence of poliomyelitis (45% of the cases) were observed during July, August, and September, corresponding to the well demarcated monsoon season. This suggests a need to intensify immunization coverage during the low polio incidence period, namely, November to April. Polio vaccine was introduced in the national immunization program in 1980. The schedule recommends 3 doses of oral polio vaccine (OPV), starting from the age of 3 months with intervals not less than 1 month. DPT and polio vaccine are administered to the child at the same time. 1 booster dose of OPV is recommended 12-18 months later. The live attenuated OPV, not produced in India is used in the national program. The requirement of the program is met by import of bulk concentrated vaccine separately for type 1, type 2, and type 3. Then, it is diluted, blended, and ampouled by Haffkine Biopharmaceutical Corporation, Ltd. The recent visit of Dr. Jonas Salk has raised the issue of introduction of killed polio vaccine (KPV) in the national program. It now is claimed that 2 doses of KPV are adequate for protection, and this can be blended with DPT to make it a quadruple vaccine. The many advantages of the live OPV used in the national program are listed, including: confers both humoral and intestinal immunity like natural infection; immunity induced may be lifelong; induces antibody very quickly in a large proportion of vaccines; and oral administration is acceptable and easier to achieve.     

The expanded programme on immunization: a lasting legacy of smallpox eradication

Since the mid-1970s, the widespread establishment and implementation of the Expanded Programme on Immunization (EPI) has led to remarkable achievements in controlling vaccine preventable diseases worldwide. Today, more children than ever are being reached with immunization; interruption of poliomyelitis transmission has occurred in most countries; mortality due to measles, tetanus, diphtheria and pertussis has been reduced to record low levels. In addition, increasing numbers of vaccines are being used for infants and older age persons, such as vaccines against hepatitis A and hepatitis B, Haemophilus influenzae type b, rotavirus, pneumococcus, meningococcus, human papilloma virus (HPV) and varicella. The design of EPI reflects in large part the experience accumulated during the implementation of the intensified campaign for smallpox eradication during the period 1966-1977. At that time, the existing health infrastructure and network was found inadequate to reach most individuals with community wide immunization programmes in most countries. Thus, efforts were made to train dedicated health personnel and allocate specific resources for programme coordination and implementation. With the establishment of EPI, there was a gradual shift in emphasis from vaccination campaign strategies using mobile teams to the delivery of immunization services as part of routine health services of health facilities. Both the campaign and the outreach strategies are nevertheless required to reach those segments of the population not reached by the routine health services and to accelerate the achievement of disease control initiatives such as polio eradication and measles elimination. Whilst the campaign for smallpox eradication was set up as special and time-limited effort, the EPI requires long-term sustainable approaches to protect new cohorts of susceptible persons with vaccination and monitor trends and progress towards disease control with high quality surveillance.     

Worldwide status of poliomyelitis in 1986, 1987 and 1988, and plans for its global eradication by the year 2000

In 1986, a total of 28,951 cases of poliomyelitis were reported to WHO by 175 countries/areas. For 1987, 35,685 cases were reported by 168 countries/areas. Reporting is incomplete for 1988, based on data available as of December 1989. Trends in regional incidence rates for poliomyelitis over a 15-year period from 1974 to 1988 suggest a decline in the incidence of the disease, especially since 1982. However, the reported data underreport actual disease incidence. During 1986, 1987 and 1988, the Expanded Programme on Immunization (EPI) estimates that 200,000-250,000 cases of paralytic poliomyelitis occurred each year. With the current level of polio immunization coverage, it is estimated that 360,000 cases of paralytic poliomyelitis were prevented in 1988. In 1974, when the EPI was started, it was estimated that less than 5% of children in the developing world were adequately immunized against six common childhood diseases, including poliomyelitis. In 1988 (based on data available as of December 1989) 67% of children worldwide received a full course of polio vaccine before 12 months of age. The progress of the EPI has provided optimism that poliomyelitis can be eradicated. In May 1988, the Forty-first World Health Assembly committed WHO to the global eradication of poliomyelitis by the year 2000. The eradication of poliomyelitis will represent, along with the eradication of smallpox, a fitting gift from the XXth to the XXIst century. To reach this goal, action will be required in several main areas. Immunization coverage will need to be raised and sustained in every district. Vaccine quality must be assured by using vaccines which meet WHO requirements and maintaining the cold chain. Surveillance must be strengthened so that prompt, regular reporting of suspected cases leads to disease-containment measures. Additional actions include improving laboratory diagnostic capabilities, developing special training materials, increasing public awareness, supporting rehabilitation services and conducting essential research.     

Immunization

Immunization is an essential component of primary health care and child survival activities throughout the world. Since the establishment of the World Health Organization's Expanded Programme on Immunization (EPI) in 1974, the estimated incidence of childhood vaccine-preventable diseases has declined significantly. Today, immunization against the 6 diseases targeted by EPI--diphtheria, measles, pertussis, polio, tetanus and tuberculosis--prevents approximately 2 million childhood deaths per year. Nevertheless, many women and children in the developing world remain unimmunized, resulting in the death or disability from vaccine-preventable diseases of over 3 million children annually. Currently, efforts are focused on expanding immunization services for women and children with the goal of protecting all children against the 6 EPI-targeted diseases. Recent initiatives call for the eradication of polio by 2000, the elimination of neonatal tetanus by 1995, and a 95% reduction in measles incidence by 1995. Expanding immunization coverage against hepatitis B and yellow fever also are objectives in areas where these diseases are endemic. To achieve these goals, current immunization program priorities include: 1) the continued use of current vaccines as well as the introduction of new more effective, and more stable ones; 2) the development and improvement of cold chain technologies to safely transport, store, and distribute vaccines; 3) the development and improvement of injection technologies to ensure proper administration of vaccines and safe handling of injection equipment; and 4) efficient program management that strives to achieve and sustain expanded coverage and service delivery through improved training, supervision, evaluation and community mobilization. The most recent developments in these areas are reviewed, updating a 1983 "Directions" issue on the same topic.     

The use of evaluation to improve the Expanded Programme on Immunization in Mozambique

Reported are the results of an evaluation of process indicators and outputs for the Expanded Programme on Immunization (EPI) in Mozambique which were used to modify immunization strategies from 1985 to 1987. In 1986 according to cluster sample surveys, 84% of children in Maputo, the capital, were fully vaccinated. In other cities in the country, vaccination coverage increased from an average of 36% in 1985 to 55% in 1987. The major determinants of low vaccination coverage were provision of vaccination services at health centres on less than 3 days per week; missed opportunities; and vaccinating too early or with too short an interval between doses. The results of sentinel site surveillance in Maputo indicated that EPI had a marked impact on neonatal tetanus and to a lesser extent on poliomyelitis and measles. Evaluation led to changes in EPI policy in Mozambique (e.g., adoption of a uniform national vaccination schedule and discontinuation of the use of expired vaccine) and strategies (elaboration of different strategies for urban areas, rural areas, and displaced people). Also, performance was improved by involving programme managers and implementors in evaluation, and by providing timely and widespread feedback of results to policy-makers, peripheral health workers, and the community.     

Childhood vaccination: achievements and challenges

As the goal of eradicating smallpox was being met, the World Health Organization created its Expanded Programme on Immunisation (EPI) in 1974 and reached its initial goal of achieving full vaccination of 80% of the world's children by 1990. This effort was aided by the creation of "cold chain" delivery systems and resulted in the annual saving of 3.5 million children in less-developed countries. Current EPI vaccination goals include 1) eradication of poliomyelitis by the year 2000, 2) elimination of neonatal tetanus by the year 1995, 3) control of measles and hepatitis B, and 4) immunization of 90% of the world's children 1 year or younger by the year 2000. Goals of the Children's Vaccine Initiative (formed in 1991) include 1) provision of an adequate supply of affordable, safe, and effective vaccines; 2) production of improved and new vaccines; and 3) simplification of the logistics of vaccine delivery. Future challenges are to sustain high vaccination coverage, reach the unreached, achieve proper storage of vaccines and reduce waste, integrate new vaccines into national programs, and achieve vaccine self-sufficiency. The fact that these challenges will be difficult to achieve is illustrated by the situation in Africa where the high immunization levels achieved in 1990 have dropped dramatically. Those who must act to implement immunization programs are health personnel, families, governments, and development partners. In order to achieve equity in health, every child must be reached, governments must be made accountable for programs, health workers must convince families of the importance of vaccination, delivery systems must be in place to take advantage of the new vaccines being delivered, and a multisectoral approach must be taken to assure sustainability.     

Global public health mandates in a diverse world: the polio eradication initiative and the expanded programme on immunization in sub-Saharan Africa and South Asia

BACKGROUND: The circulation of wild poliovirus is expected to cease soon due to the success of the global polio eradication initiative. Thereafter, intensified polio eradication efforts such as National Immunisation Days (NIDs) will most likely be discontinued. As a consequence, the expanded programme on immunization (EPI) will no longer enjoy extra inputs from the polio eradication initiative. We investigated whether today's EPIs are ensuring universal and equitable vaccine coverage; and whether the removal of extra inputs associated with the implementation of NIDs is likely to affect EPI coverage and equity. METHODS: Using data from Demographic and Health Surveys conducted in 15 countries of South Asia and Africa during 1990-2001, we examined absolute levels of EPI coverage; changes in EPI coverage after the introduction of NIDs; and relative coverage according to urban versus rural residence, higher versus lower education of mothers, and wealthiest vs. poorest population segment. RESULTS: Polio and non-polio antigen coverage increased in seven countries during the study period. Substantial inequalities in coverage of non-polio antigens persist, however, translating into inequities in the risk of contracting vaccine preventable diseases. In some African countries, routine EPI coverage and/or equity declined during the study period. In these countries, any positive effect of NIDs on the EPI coverage must have been small, relative to the negative effects of declining economies or deteriorating health systems. In Nigeria, Zimbabwe, Kenya and Malawi, even polio coverage declined, in spite of the introduction of NIDs. CONCLUSION: As additional inputs associated with polio eradication will cease, routine EPI services need to be strengthened substantially in order to maintain levels of population immunity against polio and to improve social equity in the coverage of non-polio EPI antigens. Our findings imply that this aim will require additional inputs, particularly in African countries.     

新疆维吾尔自治区2016－2017年免疫规划疫苗损耗调查

目的 了解新疆维吾尔自治区预防接种单位免疫规划（EPI）疫苗的损耗现状，为进一步精细化管理和使用EPI疫苗提供依据。方法 采取分层整群抽样方法抽取135个接种单位，调查2016-2017年6种EPI疫苗接种和使用数据，包括常规免疫和脊髓灰质炎疫苗群体性补充免疫活动中疫苗领发和使用数量、疫苗报废记录，以及接种单位的地区类型、服务模式、接种周期、日均接种量等。采用描述流行病学方法计算和分析疫苗的损耗系数。结果 单人份的无细胞百白破联合疫苗（DTaP）和三价脊髓灰质炎减毒活疫苗（tOPV）损耗系数最低，分别为1.00和1.02；多人份的二价脊髓灰质炎减毒活疫苗（bOPV）、A群脑膜炎球菌多糖疫苗（MPV-A）、白喉破伤风联合疫苗（DT）、卡介苗（BCG）损耗系数分别为1.58、1.67、1.68、3.02。城市、农村、牧区接种单位EPI疫苗损耗系数范围分别为1.00~2.84、1.00~3.71、1.00~2.27；乡级集中、村级集中、分散接种模式的损耗系数分别为1.00~3.00、1.00~4.41、1.00~1.94。接种周期越长或日均接种量越小，损耗系数越大。结论 新疆维吾尔自治区预防接种单位多人份EPI疫苗损耗较高，并受地区和接种服务形式的影响。需根据地区类型、接种单位服务形式等加强精细化的疫苗管理，减少疫苗损耗和浪费。     

The logic of causation and the risk of paralytic poliomyelitis for an American child

Beginning in January 1997, American immunization policy allowed parents and physicians to elect one of three approved infant vaccination strategies for preventing poliomyelitis. Although the three strategies likely have different outcomes with respect to prevention of paralytic poliomyelitis, the extreme rarity of the disease in the USA prevents any controlled comparison. In this paper, a formal inferential logic, originally described by Donald Rubin, is applied to the vaccination problem. Assumptions and indirect evidence are used to overcome the inability to observe the same subjects under varying conditions to allow the inference of causality from non-randomized observations. Using available epidemiologic information and explicit assumptions, it is possible to project the risk of paralytic polio for infants immunized with oral polio vaccine (1.3 cases per million vaccinees), inactivated polio vaccine (0.54 cases per million vaccinees), or a sequential schedule (0.54-0.92 cases per million vaccinees).     

Rehabilitation of the expanded programme on immunization in Sudan following a poliomyelitis outbreak.

In 1993 a large outbreak of paralytic poliomyelitis occurred in Sudan as a result of an accumulation of large numbers of susceptible children that was accelerated by faltering immunization services. The extent of the outbreak led to the rapid rehabilitation of Sudan''s Expanded Programme on Immunization (EPI); the government began financing vaccine purchase, operational aspects of EPI were decentralized, vaccine delivery was changed from a mobile to a fixed-site strategy, a solar cold chain network was installed, inservice training was resuscitated, and social mobilization was enhanced. National immunization days (NIDs) for poliomyelitis eradication were conducted throughout the country, including the southern states during a cease fire in areas of conflict. Measles immunization coverage was increased by offering measles vaccine during the second round of NIDs and subsequently through routine immunization services. Supplemental tetanus toxoid immunization of women of child-bearing age began in three provinces at high risk for neonatal tetanus. From 1994 to 1996 reported immunization coverage increased and the incidence of all EPI target diseases fell. Trends in coverage, disease incidence, financing, and the implementation of WHO-recommended disease-control strategies suggest that more sustainable immunization services have been re-established in Sudan.     

长沙市农村地区1～6岁留守儿童接种率调查及策略探讨

目的 了解长沙市农村地区适龄留守儿童扩大国家免疫规划(National Immunization Program,NIP)疫苗接种率现状.方法 采取多阶段随机抽样的方法,随机抽取20个乡镇(5个/区县)120个行政村1～6岁留守儿童,共入户调查留守儿童1 027名,非留守儿童1 150名.结果 适龄留守儿童卡介苗(bacilli calmette-guerin vaccine,BCG)、3剂乙肝疫苗(hepatitis B vaccine,HepB3)、3剂脊髓灰质炎减毒活疫苗(oral poliomyelitis attenuated live vaccine,OPV3)、第4剂OPV(OPV4)、3剂次百白破疫苗(diphtheria,tetanus and pertussis combined vaccine,DTP3)、第4剂DTP(DTP4)、第1剂含麻疹疫苗(measles-containing vaccine,MCV1)、第2剂MCV(MCV2)、第1剂乙脑疫苗(japanese encephalitis vaccine,JEV1)、第2剂乙脑疫苗(JEV2)、第1剂A群流脑疫苗(group A meningococcal polysaccharide vaccine,MPV-A1)、第2剂A群流脑疫苗(MPV-A2)、第1剂A+C群流脑疫苗(group A and C meningococcal polysaccharide vaccine,MPV-AC1)、甲肝疫苗(hepatitis A vaccine,HepA)的接种率分别为99.5％、98.3％、99.1％、62.4％、98.7％、86.2％、97.6％、91.7％、93.5％、71.2％、98.2％、83.0％、48.0％和81.5％;留守儿童MCV1、MCV2、OPV4、DTP4、JEV1、JEV2、MPV-A2及MPV-AC1接种率均低于非留守组儿童且差异有统计学意义(x2值分别为5.38,7.66,4.41,4.77,4.21,10.87,4.93,5.04,均有P＜0.05).结论 长沙市农村地区适龄留守儿童基础免疫接种率大部分达国家要求,但加强免疫接种率相对较低,且均低于非留守组儿童,需采取针对性措施,提高接种率,降低农村留守儿童疫苗可预防传染病的发病率.     

National vaccine coverage trends and funding in Latin America and the Caribbean

BackgroundFrom 2006 to 2011 nearly 174,000 deaths were prevented in Latin America and the Caribbean through vaccination of children under five, which is widely attributed to the Expanded Program on Immunization (EPI). Despite near global adoption of EPI recommendations, vaccination coverage shows substantial variation across world regions. Causes for low immunizations within regions are multifaceted and include vaccination program costs. To date, publications regarding vaccine coverage across Latin America and the Caribbean are not readily available. This study aimed to: (1) compare vaccine coverage trends across nations within the region; and (2) assess whether national immunization program expenditures are correlated with vaccine coverage.MethodsCoverage for nine vaccines were collected by nation using publicly available data from WHO. National immunization program expenditures for each country were collected from the World Bank Index. The proportion of countries achieving 90% coverage in the years 2013 and 2017 for each vaccine were compared. Pearson correlation coefficients were calculated to measure the relationship between financing variables and DTP3 coverage for 2017.ResultsIn 2017, fewer Latin American and Caribbean nations were able to achieve 90% vaccine coverage for five vaccines compared to 2013. Mostly weak to moderate positive relationships were found between national immunization program expenditures and DTP3 coverage for 2017. Excluding Haiti, a weak negative relationship was found between total government expenditure on vaccines per infant and DTP3 coverage for 2017. Countries across Latin America and the Caribbean were largely self-reliant in funding vaccine expenditures.ConclusionsFewer countries across Latin America and the Caribbean are currently achieving optimum national vaccine coverage and weak to moderate relationships between routine immunization and vaccine expenditures and coverage were observed. Additional factors contributing to national vaccine coverage should be concomitantly examined to implement strategies which optimize delivery of childhood immunizations.     

Global immunization: status,progress, challenges and future

Vaccines have made a major contribution to public health, including the eradication of one deadly disease, small pox, and the near eradication of another, poliomyelitis.Through the introduction of new vaccines, such as those against rotavirus and pneumococcal diseases, and with further improvements in coverage, vaccination can significantly contribute to the achievement of the health-related United Nations Millennium Development Goals.The Global Immunization Vision and Strategy (GIVS) was developed by WHO and UNICEF as a framework for strengthening national immunization programmes and protect as many people as possible against more diseases by expanding the reach of immunization, including new vaccines, to every eligible person.This paper briefly reviews global progress and challenges with respect to public vaccination programmes.The most striking recent achievement has been that of reduction of global measles mortality from an estimated 750,000 deaths in 2000 down to 197,000 in 2007. Global vaccination coverage trends continued to be positive. In 2007 most regions reached more than 80% of their target populations with three doses of DPT containing vaccines. However, the coverage remains well short of the 2010 goal on 90% coverage, particularly in the WHO region of Africa (estimated coverage 74%), and South-East Asia, (estimated coverage 69%). Elements that have contributed to the gain in immunization coverage include national multi-year planning, district-level planning and monitoring, re-establishment of outreach services and the establishment of national budget lines for immunization services strengthening.Remaining challenges include the need to: develop and implement strategies for reaching the difficult to reach; support evidence-based decisions to prioritize new vaccines for introduction; strengthening immunization systems to deliver new vaccines; expand vaccination to include older age groups; scale up vaccine preventable disease surveillance; improve quality of immunization coverage monitoring and use the data to improve programme performance; and explore financing options for reaching the GIVS goals, particularly in lower-middle income countries.Although introduction of new vaccines is important,this should not be at the expense of sustaining existing immunization activities. Instead the introduction of new vaccine introduction should be viewed as an opportunity to strengthen immunization systems, increase vaccine coverage and reduce inequities of access to immunization services.     

江东区5种二类疫苗接种情况分析

目的 分析江东区5种二类疫苗接种情况.方法 选取江东区13 133例2～5周岁的儿童为研究对象,分析其二类疫苗接种情况.结果5种二类疫苗接种率在7.04％～88.24％之间,平均接种率为36.32％;除水痘疫苗外,其余4种疫苗的接种率流动儿童均高于本地儿童;流动儿童5种二类疫苗平均接种率为38.03％,本地儿童平均接种率为34.43％.结论该区流动儿童二类疫苗接种率高于本地儿童;将更多二类疫苗纳入一类疫苗管理是提高二类疫苗接种率的最有效方法.     

The immunisation programme in the Caribbean

The Directing Council of Pan American Health Organization approved a resolution concerning the formal inauguration of the Expanded Programme on Immunization (EPI) in the Americas in October 1977. Subsequently, the EPI entered full implementation in those countries that were members of the Caribbean Epidemiology Center (CAREC) during 1978-80. All 19 CAREC Member Countries (CMC) were conducting routine immunization with diphtheria, pertussis, tetanus, poliomyelitis, measles and BCG vaccines by 1980. The establishment of the program in these countries resulted in focused activities, including training and the development of operational guidelines. Health education has been primarily used to encourage mothers to have their children vaccinated at optimum age, and to advise parents and guardians about adverse reaction to vaccines. Great efforts have been made in immunization coverage in all the CMCs for the six vaccine preventable diseases. The eradication of poliomyelitis, the interruption of measles transmission (8 years measles-free), and the implementation of strategies for the elimination of rubella and CRS have presented many challenges to public health practitioners in the region. The success of all these initiatives is a reflection of the deep commitment and strong partnerships, which have been developed between the governments, health practitioners, and people of the region. Moreover, technical and financial support from both international agencies and service clubs played a major role in the success of the program.     

Immunization coverage in tribal and rural areas of Visakhapatnam district of Andhra Pradesh,India

Objective  This paper aims to report and compare the immunization coverage of various vaccines among tribal and rural children in a distinct socio-economic environment in India. Methods  The study was conducted in two tribal and two rural developmental blocks of Visakhapatnam district of Andhra Pradesh, India, by employing both qualitative and quantitative data collection techniques. Data collected included the immunisation coverage and the associated socio-demographic factors. Results  The majority of mothers was aware of vaccination of children, and usually the primary heath centres and their health workers were the source of vaccination. Vaccination cards were received by 79.2% of tribal and 71.3% of rural children. Some of the socio-demographic characters of mothers, such as habitat, caste and occupation, were associated with the reception of a vaccination card. The coverage of various vaccines was higher among the tribal than among the rural population. Of the eligible children aged above 9 months, 63.3% of tribal children and only 14.5% of rural children were fully vaccinated [three doses of diphtheria, pertussis and tetanus (DPT), four doses of oral polio vaccine, Bacille Calmette Guerin (BCG) and measles vaccine]. The coverage of vaccination against measles and vitamin-A supplementation were very low among rural children (19.6% and 15.2%, respectively) when compared to tribal children (69.2% and 64.2%, respectively). The qualitative data indicated that the community was not satisfied with regard to vaccination services, particularly in the rural area. Conclusion  The coverage of various vaccines was moderate in tribal areas and poor in rural areas. The sole dependence on and demand for public health services was responsible for relatively better coverage of immunisation in tribal areas compared to rural areas where the private sector plays a major role. The existing strategies of health-care delivery including delivery of vaccination services need to be examined and improved. Improvements in physical access, infrastructure, quality of care and increased use of mass media and interpersonal communication are indispensable for improvement in the provision of services.