Routine Immunization: The Missed Child Perspective

1. Maya van den Ent, PharmD MPH Edward Hoekstra, MD, MSc David Brown, DSc, MScPH, MSc Halima Dao, MD, MSc Satish Gupta, MD Routine Immunization: The Missed Child Perspective

2. Coverage MCV1 globally and in 47 priority countries Source: WHO/UNICEF immunization coverage for 2010

3. MCV1 Coverage 2000 – 201047 Priority Countries 2000 2005 2010 Source: WHO/UNICEF immunization coverage for 2010

4. Human 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.

5. Child 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.

6. The poorest are more likely to die Indonesia Under 5 Mortality Rate by Wealth Quintiles 2002 - 2003

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

8. Every seventh child not reached 19.1 million infants not having received MCV1, 2010

9. Reasons for under- or un-vaccination Under – vaccinated Unvaccinated Family Character- istics Parental Attitudes And Knowledge Immunization Systems % based on 33 reasons abstracted from 12 articles on unvaccinated children % based on 887 reasons abstracted from 209 relevant articles Under vaccinated: Infants received at least one vaccine, but no DTP3 Un-vaccinated: Infants received no vaccine at all

10. India: Immunization coverage varies significantly among different population categories Percentage of children age 12-23 fully immunized District Level Household Survey 2007-2008

11. India: Where are the unvaccinated? Children not vaccinated with DPT3 Source: DLHS 2007-08; children surveyed were between 12-23 months

12. India: Where are the unvaccinated ? District - level percentage of fully immunized children Wide intra-state variations Source: DLHS 2007-08; children surveyed were between 12-23 months

13. India – Predictors Only at least one vaccine vs fully immunized Poor Education Mother no TT2+ Minority religion Rural No Radio/TV Poor Source: Swiss Tropical Institute 2010

14. The poorest are more likely not to be immunized

15. Greater disparities between provinces than rural urban

16. How to Reach the Under-served Possible links between SIAs and RI Measles Partnership explores ways to further strengthen routine immunization in 2012 Plan for critical activities strengthening routine during SIA planning

17. Possible 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

18. Possible 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

19. Measles campaigns reach the poorest Nationwide Measles Vaccination Coverage by Wealth Quintile, Kenya, 2002 Source: VijayaraghavanM, et al. Health Policy 2007, 83: 27-36 Source: Vijayaraghavan M, Health Policy 2006

20. Conclusions • 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