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International Health 3 (2011) 12

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International Health
journal homepage: http://www.elsevier.com/locate/inhe

Commentary

Avoiding complacency and maintaining progress in routine immunization

a r t i c l e
Keyword: Immunization

i n f o

a b s t r a c t
A review of estimated coverage with three doses of diphtheria, tetanus, pertussis vaccine (DTP3) suggests many countries will not meet the Global Immunization Vision and Strategy (GIVS) goal to increase national immunization coverage levels to at least 90% by 2010 and to sustain these levels through at least 2015. In fact, 42% of low-income countries have made insufcient or no progress towards the goal, compared to 8% of high-income countries. Despite enormous and increasingly successful efforts to address the global burden of vaccine-preventable diseases and extraordinary improvements in universal childhood immunization, opportunities remain to improve routine immunization coverage globally. 2010 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.

Prior to 1980 few countries had established routine immunization systems. When the Expanded Programme on Immunization (EPI) was launched in 1974, less than 5% of the worlds children were immunized during their rst year of life against polio, diphtheria, tuberculosis, pertussis, measles and tetanus.1 In fact, improvements in immunization coverage did not manifest until the 1980 s, during which time the EPI made remarkable strides towards achieving universal childhood immunization coverage as exemplied by increases in coverage with three doses of diphtheria, tetanus, pertussis vaccine (DTP3) before a childs rst birthday from 20% in 1980 to 75% in 1990.2 By 1990, DTP3 coverage levels were greater than 80% in 108 countries, covering 43% of all children, and fewer than 10% of children lived in countries with under 50% coverage a dramatic change from 1980 when more than 90% of the worlds children lived in 147 of 167 countries with DPT3 coverage levels less than 80%.2 By 2009, estimated global coverage with DTP3 was 82%.3 In response to challenges in global immunization, WHO, UNICEF and partners developed the Global Immunization Vision and Strategy (GIVS).4 One goal of the GIVS was to increase national immunization coverage levels to at least 90% by 2010 and to sustain these levels through at least 2015. Unfortunately, one year before the 2010 target, many will not meet this goal nor the one set for 2015 (Figure 1). An examination of DTP3 coverage data from WHO and UNICEF

for the period 19902009 suggests that 47 of 194 countries and territories have made either insufcient or no progress towards reaching the objective. For the purposes here, countries and territories were considered on track for the objective if they had reached 90% coverage by 2009 as well as those for which the computed average annual percent increase based on a linear relationship between the log of coverage and year during 20002009 (i.e., the most recent 10-year period during which a renewed emphasis was placed on immunization by The Global Alliance for Vaccines and Immunisation (GAVI), the Millennium Development Goals and GIVS) was greater than or equal to the average annual percent increase needed to reach 90% by 2015 (for those areas that had not reached 90% coverage by 2009). Areas with an average annual percent increase during 20002009 that was less than the average annual percent increase needed to reach 90% by 2015 were considered to have made insufcient progress while those with decreasing coverage levels during 20002009 were considered to have made no progress. Forty-two per cent of low-income countries, as dened by The World Bank, have made insufcient or no progress towards the goal, compared to 28% of lower-middle-income countries, 22% of upper-middle-income countries and 8% of highincome countries. Nearly all high-income countries (92%) have either already reached 90% coverage or are on track to do so by 2015, compared to 58% of low-income countries.

1876-3413/$ see front matter 2010 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.inhe.2010.12.003

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2 Commentary / International Health 3 (2011) 12

Figure 1. Progress of countries towards reaching 90% DTP3 coverage by 2015 by country income classication. Note: The Cook Islands (insufcient), Nauru (on track), Niue (on track), and occupied Palestinian territory (on track) are not classied under the World Bank income group scheme and are not included in the graphic. Source: WHO/UNICEF estimates of national immunization coverage, 2010;3 World Bank country classication available online at http://data.worldbank. org/about/country-classications/country-and-lending-groups.

Although there have been enormous and increasingly successful efforts to address the global burden of vaccine-preventable diseases and to improve immunization coverage, opportunities remain to improve routine immunization coverage globally. During 2009 an estimated 23 million infants did not receive the three doses of DTP necessary for immunization, and large differences in immunization coverage between countries are compounded by disparities within countries. And, as disturbing as it is that 42% of low-income countries are not on track to reach 90% coverage by 2015, it is equally disturbing that nearly one in four upper-middle-income countries are not on track given the resources available in these countries. While an overemphasis should not be placed on particular targets in lieu of continuous improvement in routine immunization, the data presented here signal that countries must take more actions to ensure that more children are reached with immunization. The beginning of the Decade of Vaccines5 will provide an opportunity to explore new ways to take immunization forward, but also to reect on and re-examine existing processes. Introduction of existing new vaccines against pneumonia and diarrhoea, two of the leading causes of death worldwide, and the development of a malaria vaccine have the potential to save many more lives, but their success will depend on how well children can be reached. This is not a time for complacency: immunization programs worldwide continue to require investments and commitments in order to have maximal impact on childrens lives. Disclaimer: The opinions expressed here are those of the authors alone and do not necessarily reect the positions of their respective institutions. Authors contributions: All authors were involved in the writing and critical revision of this communication; DWB is guarantor of the paper. Acknowledgements: The authors wish to thank Dr Jos Vandelaer for his comments on earlier versions of this communication.

Funding: None. Conicts of interest: None declared. Ethical approval: Not required. References
1. Bland J, Clements J. Protecting the worlds children: the story of WHOs immunization programme. World Health Forum 1998;19:16273. 2. Burton AH, Monasch R, Lautenbach B, Gacic-Dobo M, Neill M, Karimov R, et al. WHO and UNICEF estimates of national infant immunization coverage: methods and processes. Bull World Health Organ 2009;87:53541. 3. WHO. WHO/UNICEF estimates of national immunization coverage. Geneva: World Health Organization; 2010. www.who.int/ immunization monitoring/routine/immunization coverage/en/index 4.html.[accessed 15 August 2010]. 4. Bilous J, Eggers R, Gasse F, Jarrett S, Lydon P, Magan A, et al. A new global immunisation vision and strategy. Lancet 2006;367:14646. 5. Gates Foundations decade of vaccines. Lancet Infect Dis 2010, 10:139.

David W. Brown a, Rouslan Karimov a Marta Gacic-Dobo b Anthony Burton b Jean-Marie Okwo-Bele b a United Nations Childrens Fund (UNICEF), 3 UN Plaza, New York, New York 10017, USA b World Health Organization (WHO), Geneva, Switzerland author. Tel.: +1 212 303 79 88. E-mail address: dbrown@unicef.org (D.W. Brown) 17 August 2010 1 December 2010 21 December 2010
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