Jos Vandelaer

Maternal and neonatal tetanus

Maternal and neonatal tetanus are important causes of maternal and neonatal mortality, claiming about 180 000 lives worldwide every year, almost exclusively in developing countries. Although easily prevented by maternal immunisation with tetanus toxoid vaccine, and aseptic obstetric and postnatal umbilical-cord care practices, maternal and neonatal tetanus persist as public-health problems in 48 countries, mainly in Asia and Africa. Survival of tetanus patients has improved substantially for those treated in hospitals with modern intensive-care facilities; however, such facilities are often unavailable where the tetanus burden is highest. The Maternal and Neonatal Tetanus Elimination Initiative assists countries in which maternal and neonatal tetanus has not been eliminated to provide immunisation with tetanus toxoid to women of childbearing age. The ultimate goal of this initiative is the worldwide elimination of maternal and neonatal tetanus. Since tetanus spores cannot be removed from the environment, sustaining elimination will require improvements to presently inadequate immunisation and health-service infrastructures, and universal access to those services. The renewed worldwide commitment to the reduction of maternal and child mortality, if translated into effective action, could help to provide the systemic changes needed for long-term elimination of maternal and neonatal tetanus.

The imperative for stronger vaccine supply and logistics systems

With the introduction of new vaccines, developing countries are facing serious challenges in their vaccine supply and logistics systems. Storage capacity bottlenecks occur at national, regional, and district levels and system inefficiencies threaten vaccine access, availability, and quality. As countries adopt newer and more expensive vaccines and attempt to reach people at different ages and in new settings, their logistics systems must be strengthened and optimized. As a first step, national governments, donors, and international agencies have crafted a global vision for 2020 vaccine supply and logistics systems with detailed plans of action to achieve five priority objectives. Vaccine products and packaging are designed to meet the needs of developing countries. Immunization supply systems support efficient and effective vaccine delivery. The environmental impact of energy, materials, and processes used in immunization systems is minimized. Immunization information systems enable better and more timely decision-making. Competent and motivated personnel are empowered to handle immunization supply chain issues. Over the next decade, vaccine supply and logistics systems in nearly all developing countries will require significant investments of time and resources from global and national partners, donors, and governments. These investments are critical if we are to reach more people with current and newer vaccines.

Reaching Every District (RED) approach: a way to improve immunization performance

In their paper, Victora et al.1 show that “child survival interventions are inequitably distributed within low- and middle-income countries”. Areas of greatest need were not prioritized, and expansion of these health programmes in more difficult areas has tended to be delayed or postponed. In response, we wish to share some results and propose a way forward based upon experiences with immunization programmes. Immunization programmes around the world have recognized and strived to reduce inequity for many years. While Universal Child Immunization (UCI) of 80% coverage was achieved in 1990, this merely emphasized the need to balance the inequalities within and between countries. Accordingly, several approaches were adopted. The “high risk approach” was designed in the mid-1990s to reach women in underserved areas with tetanus toxoid immunization using a campaign-style approach.2 District level microplanning has been the cornerstone of the polio eradication and measles elimination initiatives, to maximize the delivery of vaccines to all districts, especially underserved populations. District-level coverage and disease surveillance data are now routinely collected in most countries, with reporting of selected indicators to the global level since 2000. In 2002, the Reaching Every District (RED) approach was developed and introduced by WHO, the United Nations Children’s Fund (UNICEF) and other partners in the GAVI Alliance to improve immunization systems in areas with low coverage. Far from being a programme, or separate initiative, the approach outlines five operational components that are specifically aimed at improving coverage in every district: re-establishment of regular outreach services; supportive supervision: on-site training; community links with service delivery; monitoring and use of data for action; better planning and management of human and financial resources.3 The RED approach encourages countries to use coverage data to make an analysis of the distribution of unimmunized infants, and thereby prioritize districts with poor access and utilization of immunization, while districts are encouraged to make microplans to identify local problems and adopt corrective solutions. Since 2003, 53 developing countries have started implementing RED to various degrees, mostly in Africa and south and south-east Asia.4 All 53 countries belong to the groups of lower income and lower-middle income countries, as per World Bank classification. In 2005, an evaluation of 5 countries in Africa that had implemented RED found that, in 4 of the 5 countries, immunization coverage had increased since the implementation of RED, and that the proportion of districts with DTP3 (three-dose diphtheria, tetanus and pertussis vaccine) coverage above 80% had more than doubled.5 The number of unimmunized children in these 5 countries was reduced from 3 million in 2002 to 1.9 million in 2004. Interestingly, the report notes that outreach services, one of the five components of RED, were often used to deliver other interventions beyond immunization, such as Vitamin A, antihelminthic drugs or insecticide-treated bed nets. This indicates that implementation of RED components may start to have an impact beyond immunization services alone. An analysis of coverage data supports the findings of the evaluation in Africa. It shows that in the 53 countries that started to implement RED between 2003 and 2005, DTP3 coverage (as estimated by WHO and UNICEF) increased between 2002 and 2005 in 34 (64%) countries, and decreased in only 7 (13%).6 Although these data need to be interpreted with caution, since RED implementation has not been nationwide in many countries, they seem to indicate that where RED is implemented, it can help to reduce gaps in immunization coverage. We agree with the suggestion of Victora et al. regarding the need for information systems and training. Most of the 53 countries we refer to have functional immunization information, logistics and supply systems and have implemented district training, often using funds from the GAVI Alliance. Furthermore WHO, UNICEF and other partners at country and regional level have been closely involved in guiding countries adopting the RED approach to reach the unreached. We believe that the RED approach of district microplanning based upon local data using simple operational components and supported by supply and logistics has the potential for the successful delivery of other child health interventions, especially during outreach. ■

A new global immunisation vision and strategy

The widespread establishment of immunisation programmes over the past 30 years has provided remarkable achievements. Smallpox was eradicated the worldwide incidence of poliomyelitis has dropped 99% since 1988 and more than 2 million children’s deaths from diphtheria tetanus pertussis and measles are prevented each year (figure). Hepatitis B vaccination could annually prevent an additional 600 000 future deaths (from liver cirrhosis and hepatoma).4 More than 75% of children younger than 1 year of age receive three doses of diphtheria tetanus and pertussis and at least one dose of measles vaccine. Despite such success serious challenges remain. In 2002 an estimated 1.4 million children—13% of the 10.5 million children who die each year (2000-03)—died of diseases preventable with widely available vaccines for pertussis measles tetanus Haemophilus influenzae type b poliomyelitis diphtheria and yellow fever. More efforts are needed to immunise the un-immunised and save lives. (excerpt)

A mid-term assessment of progress towards the immunization coverage goal of the Global Immunization Vision and Strategy (GIVS)

BackgroundThe Global Immunization Vision and Strategy (GIVS) (2006-2015) aims to reach and sustain high levels of vaccine coverage, provide immunization services to age groups beyond infancy and to those currently not reached, and to ensure that immunization activities are linked with other health interventions and contribute to the overall development of the health sector.ObjectiveTo examine mid-term progress (through 2010) of the immunization coverage goal of the GIVS for 194 countries or territories with special attention to data from 68 countries which account for more than 95% of all maternal and child deaths.MethodsWe present national immunization coverage estimates for the third dose of diphtheria and tetanus toxoid with pertussis (DTP3) vaccine and the first dose of measles containing vaccine (MCV) during 2000, 2005 and 2010 and report the average annual relative percent change during 2000-2005 and 2005-2010. Data are taken from the WHO and UNICEF estimates of national immunization coverage, which refer to immunizations given during routine immunization services to children less than 12 months of age where immunization services are recorded.ResultsGlobally DTP3 coverage increased from 74% during 2000 to 85% during 2010, and MCV coverage increased from 72% during 2000 to 85% during 2010. A total of 149 countries attained or were on track to achieve the 90% coverage goal for DTP3 (147 countries for MCV coverage). DTP3 coverage ≥ 90% was sustained between 2005 and 2010 by 99 countries (98 countries for MCV). Among 68 priority countries, 28 countries were identified as having made either insufficient or no progress towards reaching the GIVS goal of 90% coverage by 2015 for DTP3 or MCV. DTP3 and MCV coverage remained < 70% during 2010 for 16 and 21 priority countries, respectively.ConclusionProgress towards GIVS goals highlights improvements in routine immunization coverage, yet it is troubling to observe priority countries with little or no progress during the past five years. These results highlight that further efforts are needed to achieve and maintain the global immunization coverage goals.

Process of neonatal tetanus elimination in Nepal

BACKGROUND In late 2005, Nepal demonstrated through surveys that it had reached the World Health Organization criterion for having eliminated neonatal tetanus (NT), i.e. NT cases occurred at a rate of less than 1 per 1000 live births in every district. This paper summarizes how a combination of strategies contributed to this success. METHODS For each of the 4 strategies (clean delivery, routine immunization, supplemental immunization campaigns, and surveillance) activities before and after 2000 are described and achievements are summarized using published and unpublished data. RESULTS Through routine immunization of pregnant women with tetanus toxoid (TT), NT cases had decreased substantially by 1999, but the final push was provided through the national TT supplemental immunization activities in 2000-2004, which raised the proportion of children protected at birth against tetanus to above 80%. Fewer than 20% of deliveries take place with trained assistance. Although NT surveillance has improved since the extensive Acute Flaccid Paralysis/Polio surveillance infrastructure in Nepal was made available for the NT elimination initiative, it is likely that a number of cases still occur without being reported, particularly in rural areas. CONCLUSIONS NT elimination was achieved in 2005 in Nepal, but activities must continue and be strengthened to ensure that NT incidence will not increase in the future. The introduction and further expansion of school-based immunization will, in combination with diphtheria-tetanus-pertussis vaccine given in infancy, reduce the need for future cohorts of childbearing age women to be immunized at every pregnancy. However, booster doses will still need to be given in early adulthood to ensure ongoing protection.

Applying an equity lens in the Decade of Vaccines

Addressing inequities in immunisation must be the main priority for the Decade of Vaccines. Children who remain unreached are those who need vaccination - and other health services - most. Reaching these children and other underserved target groups will require a reorientation of current approaches and resource allocation. At the country level, evidence-based and context-specific strategies must be developed to promote equity in ways that strengthen the system that facilitates vaccination, are sustainable and extend benefits across the life cycle. At the global level, more attention must go on ensuring sustainable and affordable supply for low- and middle-income countries to vaccine products that are appropriate for the contexts where needs are greatest. Finally, data must be disaggregated and used at all levels to monitor and guide progress to reach the unreached.

Using a school-based approach to deliver immunization—global update.

Vaccines, such as HPV vaccine, are increasingly administered to school-age children, and school-based immunization is an approach that can be used to reach these children. Limited information has thus far been published that provides an overview of the school-based approach worldwide. This article, based on self-reported data from countries, summarizes the extent to which a school-based immunization approach is used around the world, and what antigens are most frequently being administered. Of the 174 countries for which data on school-based immunization were available, ninety five countries reported using a school-based approach for immunization. Children in grades 1 and 6 (or at an age corresponding with these grades) are most often targeted, and tetanus and diphtheria toxoids are the most frequently administered antigens. The impact of the school-based approach may be reduced in areas with low school attendance, unless specific measures are taken to target out-of-school children. Methods to monitor coverage need to be standardized and data on coverage and on the reach of the approach need to be more systematically analyzed and reported.

Strengthening the partnership between routine immunization and the global polio eradication initiative to achieve eradication and assure sustainability.

Since the launch of the Global Polio Eradication Initiative (GPEI) in 1988, the number of polio endemic countries has declined from 125 to 3 in 2013. Despite this remarkable achievement, ongoing circulation of wild poliovirus in polio-endemic countries and the increase in the number of circulating vaccine-derived poliovirus cases, especially those caused by type 2, is a cause for concern. The Polio Eradication and Endgame Strategic Plan 2013-2018 (PEESP) was developed and includes 4 objectives: detection and interruption of poliovirus transmission, containment and certification, legacy planning, and a renewed emphasis on strengthening routine immunization (RI) programs. This is critical for the phased withdrawal of oral poliovirus vaccine, beginning with the type 2 component, and the introduction of a single dose of inactivated polio vaccine into RI programs. This objective has inspired renewed consideration of how the GPEI and RI programs can mutually benefit one another, how the infrastructure from the GPEI can be used to strengthen RI, and how a strengthened RI can facilitate polio eradication. The PEESP is the first GPEI strategic plan that places strong and clear emphasis on the necessity of improving RI to achieve and sustain global polio eradication.

Polio Endgame: Lessons Learned From the Immunization Systems Management Group

Abstract The Immunization Systems Management Group (IMG) was established to coordinate and oversee objective 2 of the Polio Eradication and Endgame Strategic Plan 2013–2018, namely, (1) introduction of ≥1 dose of inactivated poliovirus vaccine in all 126 countries using oral poliovirus vaccine (OPV) only as of 2012, (2) full withdrawal of OPV, starting with the withdrawal of its type 2 component, and (3) using polio assets to strengthen immunization systems in 10 priority countries. The IMG’s inclusive, transparent, and partnership-focused approach proved an effective means of leveraging the comparative and complementary strengths of each IMG member agency. This article outlines 10 key factors behind the IMG’s success, providing a potential set of guiding principles for the establishment and implementation of other interagency collaborations and initiatives beyond the polio sphere.