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Assessing the cost of vaccine preventable diseases (VPD) surveillance is becoming more important in the context of the Global Polio Eradication Initiative (GPEI) funding transition, since GPEI support to polio surveillance helped the incremental building of VPD surveillance systems in many countries, including low income countries such as Nepal. However, there is limited knowledge on the cost of conducting VPD surveillance, especially the national cost for surveillance of multiple vaccine-preventable diseases. The current study sought to calculate the economic and financial costs of Nepal’s comprehensive VPD surveillance systems from July 2016 to July 2017. At thecentral level, all surveillance units were included in the sample. At sub-national level, a purposive sampling strategy was used to select a representative sample from locations involved in conducting surveillance. The sub-national sample costs were extrapolated to the nationwide VPD surveillance system. Nepal’s total annual economic cost of VPD surveillance was USD 4.81 million or USD 0.18 per capita, while the total financial cost was USD 4.38 million or USD 0.16 per capita. Government expenditures accounted for 56% of the total economic cost, and World Health Organization accounting for 44%. The biggest cost driver was personnel accounting for 51% of the total economic cost. WHO supported trained surveillance personnel through donor funding, mainly from Global Polio Eradication Initiative. As a polio transition priority country, Nepal will need to make strategic choices to fully self-finance or seek full donor support or a mixed-financing model as polio program funding diminishes.

Seven months after the April 2015 Nepal earthquake, and as relief efforts were scaling down, health authorities faced ongoing challenges in health-service provision and disease surveillance reporting.In January 2016, the World Health Organization recruited and trained 12 Nepalese medical doctors to provide technical assistance to the health authorities in the most affected districts by the earthquake. These emergency support officers monitored the recovery of health services and reconstruction of health facilities, monitored stocks of essential medicines, facilitated disease surveillance reporting to the health ministry and assisted in outbreak investigations.In December 2015 the people most affected by the earthquake were still living in temporary shelters, provision of health services was limited and only five out of 14 earthquake-affected districts were reporting surveillance data to the health ministry.From mid-2016, health facilities were gradually able to provide the same level of services as in unaffected areas, including paediatric and adolescent services, follow-up of tuberculosis patients, management of respiratory infections and first aid. The number of districts reporting surveillance data to the health ministry increased to 13 out of 14. The proportion of health facilities reporting medicine stock-outs decreased over 2016. Verifying rumours of disease outbreaks with field-level evidence, and early detection and containment of outbreaks, allowed district health authorities to focus on recovery and reconstruction.Local medical doctors with suitable experience and training can augment the disaster recovery efforts of health authorities and alleviate their burden of work in managing public health challenges during the recovery phase.Sept mois après le séisme survenu en avril 2015 au Népal, et alors que les opérations de secours s'essoufflaient, les autorités sanitaires ont été confrontées à des difficultés continues dans la prestation de services de soins et la communication en matière de surveillance des maladies.En janvier 2016, l'Organisation mondiale de la Santé a recruté et formé 12 médecins népalais afin de fournir une assistance technique aux autorités sanitaires dans les districts les plus affectés par le séisme. Ces intervenants supplémentaires d'urgence ont supervisé la reprise des services de soins et la reconstruction des établissements de soins, ont contrôlé les stocks de médicaments essentiels, ont facilité la communication avec le ministère de la Santé quant à la surveillance des maladies et ont participé aux enquêtes sur les flambées épidémiques.En décembre 2015, les personnes les plus affectées par le séisme vivaient encore dans des abris temporaires, la prestation de services de soins était limitée et seuls cinq districts affectés par le séisme sur 14 communiquaient des données de surveillance au ministère de la Santé.Depuis le milieu de l'année 2016, les établissements de soins ont progressivement été en mesure d'offrir le même niveau de services que dans les zones non affectées, avec notamment des services pédiatriques et destinés aux adolescents, le suivi des patients atteints de tuberculose, la prise en charge des infections respiratoires et les premiers secours. Le nombre de districts transmettant des données de surveillance au ministère de la Santé est passé à 13 sur 14. Le nombre d'établissements de soins en rupture de stock de médicaments a peu à peu diminué en 2016. La vérification des rumeurs de flambées épidémiques par des preuves recueillies sur le terrain, ainsi que la détection et l'endiguement précoces des épidémies, ont permis aux autorités sanitaires des districts de se concentrer sur la reprise et la reconstruction.L'appui de médecins locaux expérimentés et formés peut seconder les efforts de relèvement après catastrophe des autorités sanitaires et alléger leur charge de travail en matière de gestion des problèmes de santé publique durant la phase de relèvement.Siete meses después del terremoto en abril de 2015 en Nepal, a medida que disminuyeron los esfuerzos de ayuda humanitaria, las autoridades de salud tuvieron que enfrentar continuos desafíos para la provisión de servicios de salud y para la notificación de la vigilancia de enfermedades.En enero de 2016, la Organización Mundial de la Salud reclutó y capacitó a 12 médicos nepaleses para proporcionar asistencia técnica a las autoridades de salud en los distritos más afectados por el terremoto. Estos oficiales de apoyo supervisaron la recuperación de los servicios de salud y la reconstrucción de los establecimientos de salud, supervisaron el suministro de medicamentos esenciales, facilitaron los informes de vigilancia de enfermedades al Ministerio de Salud y asistieron en las investigaciones de brotes.En diciembre de 2015, las personas más afectadas por el terremoto seguían viviendo en alojamientos temporales, la provisión de servicios de salud era limitada y apenas cinco de los 14 distritos afectados por el terremoto realizaban informes sobre datos de vigilancia al Ministerio de Salud.Desde mediados de 2016, los centros de salud pudieron brindar gradualmente el mismo nivel de servicios que en las áreas no afectadas, incluidos los servicios pediátricos y de adolescentes, el seguimiento de pacientes con tuberculosis, el manejo de infecciones respiratorias y primeros auxilios. El número de distritos que realizaron informes sobre datos de vigilancia al Ministerio de Salud aumentó a 13 de 14. La proporción de establecimientos de salud que informaron escasez de medicamentos disminuyó en 2016. La verificación de rumores sobre brotes de enfermedades con pruebas a nivel de campo, la detección temprana y la contención de los brotes permitió que las autoridades de salud del distrito pudieran centrarse en la recuperación y la reconstrucción.Los médicos locales, con la experiencia y capacitación adecuadas, pueden contribuir a las iniciativas de las autoridades de salud en situaciones de desastre y aliviar su carga de trabajo al gestionar los desafíos de salud pública durante la fase de recuperación.بعد مرور سبعة أشهر على وقوع زلزال نيبال في شهر أبريل/نيسان 2015، ومع تراجع حجم جهود الإغاثة، فقد واجهت السلطات الصحية تحديات مستمرة تتعلق بتقديم الخدمة الصحية، وتقديم التقارير حول رصد الكارثة.عمدت منظمة الصحة العالمية في شهر يناير/كانون الثاني من عام 2016 إلى انتداب 12 طبيبًا نيباليًا وتدريبهم على أعمال تقديم المساعدة المتخصصة للسلطات الصحية في الأقاليم الأكثر تضررًا من الزلزال. وقد تولى هؤلاء المختصون بتقديم الدعم في حالات الطوارئ متابعة عملية استعادة الخدمات الصحية وإعادة تأسيس المرافق الصحية، كما رصدوا مخزون الأدوية الضرورية، وقاموا بتيسير أعمال تقديم تقارير متابعة الأمراض إلى وزارة الصحة، كما ساعدوا في جهود تقصي حالات تفشي الأمراض.في شهر ديسمبر/كانون الأول من عام 2015، كان الأشخاص الأشد تأثرًا بالزلزال لا يزالون يعيشون في ملاجئ مؤقتة، وكان تقديم الخدمات الصحية محدودًا، واقتصر رفع التقارير الخاصة ببيانات الرصد إلى وزارة الصحة على خمسة أقاليم من بين 14 إقليمًا متأثرًا بالزلزال.بدأت المرافق الصحية في استعادة قدرتها على تقديم الخدمات الصحية بنفس المستوى المقدم في المناطق غير المتأثرة اعتبارًا من أواسط عام 2016، بما يشمل خدمات طب الأطفال والمراهقين، ومتابعة مرضى السل، وإدارة حالات عدوى الجهاز التنفسي، وتقديم الإسعافات الأولية. وتزايد عدد الأقاليم التي تبلغ عن بيانات الرصد إلى وزارة الصحة ليصل إلى 13 إقليمًا من بين 14 إقليمًا. وانخفضت نسبة المرافق الصحية التي تبلغ عن نفاد مخزون الأدوية لديها على مدار عام 2016. وكان التحقق من شائعات تفشي الأمراض من خلال تحري الأدلة على المستوى الميداني والكشف المبكر عن حالات التفشي واحتوائها قد أتاح للسلطات الصحية بالأقاليم التركيز على استعادة الخدمات وإعادة تأسيسها.يمكن للأطباء المحليين ذوي الخبرة والتدريب المناسبين استكمال جهود السلطات الصحية الهادفة إلى تجاوز آثار الأزمة، وتخفيف العبء الناشئ عنها في مجال إدارة تحديات الصحة العمومية خلال مرحلة استعادة الخدمات.距 2015 年 4 月尼泊尔地震发生 7 个月后，随着救援工作的缩减，卫生当局在卫生服务提供和疾病监测报道方面面临着持续挑战。.2016 年 1 月，世界卫生组织招募并培训了 12 名尼泊尔医生，向地震中受灾最严重地区的卫生当局提供技术援助。这些紧急支援官员监督卫生服务的恢复和医疗机构的重建、监控基本药物库存、协助向卫生部报告疾病监测情况并协助疫情调查。.在 2015 年 12 月，受地震影响最严重的人们仍然住在临时避难所，提供的卫生服务很有限，14 个受灾地区中只有 5 个向卫生部报告监测数据。.从 2016 年年中开始，医疗机构逐渐能够提供与未受影响地区相同的服务水平，包括儿科和青少年服务、肺结核患者随访、呼吸道感染管理和急救。在 14 个受灾地区中，向卫生部报告监测数据的地区数量增加到 13 个。报告药品库存的医疗机构比例比 2016 年有所下降。通过实地证据核实疫情爆发的传闻，及早发现和控制疫情，使地区卫生当局能够专注于恢复和重建工作。.具有适当经验、接受过培训的当地医生可增强卫生当局的灾后恢复工作，并减轻其在恢复阶段处理公共卫生挑战的工作负担。.Спустя семь месяцев после землетрясения, произошедшего в Непале в апреле 2015 года, по мере сокращения усилий по оказанию помощи органы здравоохранения столкнулись с постоянными проблемами в области предоставления медицинских услуг и отчетности в области эпиднадзора.В январе 2016 года Всемирная организация здравоохранения набрала и обучила 12 непальских врачей для оказания технической помощи органам здравоохранения в районах, наиболее пострадавших в результате землетрясения. Эти сотрудники службы экстренной помощи контролировали восстановление службы здравоохранения и реконструкцию медицинских учреждений, проводили мониторинг запасов основных лекарственных средств, оказывали содействие в предоставлении отчетности в области эпиднадзора в Министерство здравоохранения и помогали в расследовании вспышек заболеваний.В декабре 2015 года наиболее пострадавшие от землетрясения люди все еще жили во временных убежищах, предоставление медицинских услуг было ограниченно, только пять из 14 пострадавших от землетрясения районов предоставляли отчетность о заболеваниях в Министерство здравоохранения.С середины 2016 года медицинские учреждения, включая детские медицинские учреждения, службы в области диагностики и лечения туберкулеза, постепенно смогли предоставлять тот же уровень услуг, что и в незатронутых районах, а также восстановили уровень лечения респираторных инфекций и оказания первой медицинской помощи. Количество районов, предоставляющих отчетность о заболеваниях в Министерство здравоохранения, увеличилось до 13 из 14. В 2016 году снизилась доля медицинских учреждений, сообщивших о дефиците запасов лекарственных средств. Проверка слухов о вспышках заболеваний с помощью данных, полученных на местах, а также раннее выявление и сдерживание вспышек заболеваний позволили районным органам здравоохранения сосредоточиться на восстановлении и реконструкции.Местные врачи с соответствующим опытом, прошедшие обучение, могут активизировать усилия по восстановлению после стихийных бедствий органов здравоохранения и облегчить бремя работы по решению проблем общественного здравоохранения на этапе восстановления.

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.

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.

Background: Integration of HIV infant testing into immunization sessions is one of the strategies designed to increase coverage of early infant diagnosis. Objective: To determine the evidence on the outcomes of such integration. Methods: A systematic review of peer-reviewed and grey literature was undertaken from electronic sources such as MEDLINE, Google Scholar, websites of international agencies, past conferences and ministries of health reports published between year 2002 and 2013. Randomized controlled trials, observational and qualitative studies were searched and those meeting selection criteria were selected and relevant information extracted using structured tool. Statistical pooling was not possible owing to the heterogeneity of the study designs and outcome measures. Results: Of the nine articles which met the selection criteria, none used a randomized controlled design. Of these, five articles measured mother's acceptability of their infants being tested for HIV during its first pentavalent or DPT vaccination visit, and 89·5-100% accepted. Four articles reported the proportion of mothers who returned for HIV test results, ranging from 56·8% to 86·0%. Increased uptake of HIV testing following integration was confirmed by two articles. Only one study in Tanzania determined the uptake of vaccinations following integration, with urban facilities showing stable or slight increase of monthly vaccine uptake while decreases were observed across the rural sites. In two articles, stigma was perceived by service-providers and mothers as the potential risk following integration, particularly in rural settings. Discussion: Despite the limited number of articles, the findings in this systematic review suggest that HIV testing during immunization clinic visits is acceptable and feasible as a possible model for service delivery. However, the impact on vaccination uptake needs further study.

Tetanus is a vaccine-preventable disease that yearly causes a total of 309,000 deaths. Of particular concern is maternal and neonatal tetanus (MNT), which can be prevented through immunization of the mother in pregnancy. In 2000, neonatal tetanus alone was responsible for an estimated 200,000 deaths. While the focus is on 57 priority countries, 90% of the neonatal tetanus deaths occur in 27 countries. UNICEF is spearheading the effort to eliminate MNT by the year 2005, with the support of numerous partners. MNT elimination is defined as less than one case of neonatal tetanus per 1000 live births at district level. The main strategies consist of promotion of clean delivery practices, immunization of women with a tetanus toxoid (TT) containing vaccine, and surveillance. Maternal tetanus immunization is, in most developing countries, implemented as part of the routine immunization program. However, large areas remain underserved, due to logistical, cultural, economical or other reasons. In order to achieve the target of MNT elimination by 2005, and to offer protection to women and children otherwise deprived from regular immunization services, countries are encouraged to adopt the “high risk approach”. This approach implies that, in addition to routine immunization of pregnant women, all women of child bearing age living in high risk areas are targeted for immunization with three doses of a tetanus toxoid containing vaccine (TT or Td), implemented as “supplemental immunization activities” (SIAs). Through SIAs, about 17 million women have been reached with at least two doses of TT vaccine in the past 3 years, and it is estimated that another 200 million need to be targeted in the years to come. SIAs should substantially reduce the burden of disease. Countries will also have to improve their existing immunization and clean delivery programs to ensure that the elimination of maternal and neonatal tetanus is maintained.

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.

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.

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)

On the eve of the 40th anniversary of launching of the Expanded Programme on Immunization (EPI) in 1974, during the twenty-seventh World Health Assembly (WHA), fundamental questions about the level of financing needed to sustain achievements and scale up the EPI in low- and lower-middle income countries continue to permeate the discourse on the economics of immunization. The answer to this question is all the more important in light of the fact that at the sixty-fifth WHA in 2012, ministers of health embraced the Global Vaccine Action Plan (GVAP) – a 10-year global strategic plan for immunization.1 But how much – and in what areas – are the investments needed for this decade? Today, improved transparency in pricing information allows for relatively accurate vaccine cost estimates.2 Unfortunately, trends in the health system costs of delivering vaccination beyond the cost of the vaccines themselves continue to be poorly understood. During the EPI’s first three decades of existence, they were fairly homogenous. The six basic antigens1 included in the EPI were inexpensive and health system inputs, such as the human resources for vaccination and the vaccine supply chain and logistics infrastructure, accounted for the largest share of total costs in country programmes.3 It was common knowledge that EPI vaccines represented 20% of overall investment in national immunization programmes in low- and lower-middle income countries.4 With the turn of the millennium came a paradigm shift away from this earlier established trend as countries began introducing new vaccines, such as the pentavalent vaccine, a five–in-one combination of the antigens against diphtheria, tetanus and pertussis with those against hepatitis B (HepB) and Haemophilus influenzae type b (Hib).2 During the period from 2000 to 2010, countries rapidly scaled up the use of pentavalent vaccine and, as a result, the total cost of country immunization programmes doubled or tripled.5 Recurrent investments in vaccines suddenly comprised the bulk of immunization programme costs: an average of more than 50% of total investments, and in many cases, well over this average.6 Part of the reason for this rise in the component of the total costs comprised by vaccines was that the incremental health system (i.e. non-vaccine) costs of introducing the pentavalent vaccine were marginal, since this product, despite adding two new antigens – HepB and Hib – to EPI schedules, required no more injections than the previously administered trivalent diphtheria–pertussis–tetanus (DPT) vaccine. In addition, pentavalent vaccines required little additional storage space in the vaccine cold chain.7 Looking ahead, the current decade will see the accelerated introduction into national EPI programmes of additional new, expensive, but highly effective vaccines, such as pneumococcal conjugate vaccine and the vaccines against rotavirus and human papilloma virus (HPV).3 These products are bulkier than the pentavalent vaccine and will require more cold chain storage space and more injections. The health system costs associated with delivering these newer vaccines are likely to outweigh the costs of the vaccines themselves – which reverses the trend in relative importance of vaccine to non-vaccine costs once again.

Within the overall framework set out in the Global Immunization Vision and Strategy (GIVS) for the period 2006-2015, over 70 countries had developed comprehensive Multi-Year Plans (cMYPs) by 2008, outlining their plans for implementing the GIVS strategies and for attaining the GIVS Goals at the midpoint in 2010 or earlier. These goals are to: (1) reach ≥90% and ≥80% vaccination coverage at national and district level, respectively; and (2) reduce measles-related mortality by 90% compared with the 2000 level. Fifty cMYPs were analysed along the four strategic areas of the GIVS: (1) protecting more people in a changing world; (2) introducing new vaccines and technologies; (3) integrating immunization, other health interventions and surveillance in the health system context; and (4) immunizing in the context of global interdependence. By 2010, all 50 countries planned to have introduced hepatitis B (HepB) vaccine, 48 the Haemophilus influenzae type B (Hib) vaccine and only a few countries had firm plans to introduce pneumococcal or rotavirus vaccines. Countries seem to be inadequately prepared in terms of cold-chain requirements to deal with the expected increases in storage that will be required for vaccines, and in making provisions to establish a corresponding surveillance system for planned new vaccine introductions. Immunization contacts are used to deliver other health interventions, especially in the countries in the World Health Organization (WHO) Africa Region. The cost for the planned immunization activities will double to U$27 per infant, of which U$5 per infant is the expected shortfall. Global Alliance for Vaccines and Immunization (GAVI) funding is becoming the largest contributor to immunization programmes.

Background The 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. Objective To 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. Methods We 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. Results Globally 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. Conclusion Progress 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.

BACKGROUND: Neonatal tetanus remains an important and preventable cause of neonatal mortality globally. Large reductions in neonatal tetanus deaths have been reported following major increases in the coverage of tetanus toxoid immunization, yet the level of evidence for the mortality effect of tetanus toxoid immunization is surprisingly weak with only two trials considered in a Cochrane review. OBJECTIVE: To review the evidence for and estimate the effect on neonatal tetanus mortality of immunization with tetanus toxoid of pregnant women, or women of childbearing age. METHODS: We conducted a systematic review of multiple databases. Standardized abstraction forms were used. Individual study quality and the overall quality of evidence were assessed using an adaptation of the GRADE approach. Meta-analyses were performed. RESULTS: Only one randomised controlled trial (RCT) and one well-controlled cohort study were identified, which met inclusion criteria for meta-analysis. Immunization of pregnant women or women of childbearing age with at least two doses of tetanus toxoid is estimated to reduce mortality from neonatal tetanus by 94% [95% confidence interval (CI) 80-98%]. Additionally, another RCT with a case definition based on day of death, 3 case-control studies and 1 before-and-after study gave consistent results. Based on the consistency of the mortality data, the very large effect size and that the data are all from low/middle-income countries, the overall quality of the evidence was judged to be moderate. CONCLUSION: This review uses a standard approach to provide a transparent estimate of the high impact of tetanus toxoid immunization on neonatal tetanus.

Objective Given the increased attention on the need for booster immunizations of older children and adolescents, as well as new primary vaccine series that specifically target school-age children and adolescents, we reviewed the current state of vaccine delivery to school-age children and adolescents in low- and middle-income countries. Methods We searched the published literature and unpublished sources for articles, meeting presentations, technical reports and program documents related to immunization policies and programs for school-age children and/or adolescents between 6 and 19 years of age in low- and middle-income countries. Findings We found several examples of ongoing school-age children and adolescent immunization in low- and middle-income countries. Reasons to vaccinate this age group include vaccines specifically targeted for this age group, waning immunity from prior vaccination, “catch-up” vaccination, acceleration of disease control or elimination efforts, and age distribution shift in the incidence of vaccine-preventable diseases. Multiple delivery strategies are currently in use: routine immunization, supplementary immunization activities, and Child Health Days and similar activities. Vaccines can be delivered in fixed sites, or through outreach. Most immunization programs that target adolescents and school-aged children are providing boosters of infant vaccines at school entry age, with scant experience in delivery of primary vaccination series in adolescents. Few of these programs have been formally evaluated and dissemination of lessons learned is limited. Conclusions This baseline description may facilitate immunization program planning in countries considering vaccinating this age group. Additionally, this summary may inform plans for operational research and program evaluation designed to expand vaccine delivery to school-age children and adolescents in low- and middle-income countries.

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), NTcases 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 NTsurveillance has improved since the extensive Acute Flaccid Paralysis/Polio surveillance infrastructure in Nepal was made available for the NTelimination initiative, it is likely that a number of cases still occur without being reported, particularly in rural areas. Conclusions NTelimination 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.

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 Journal’s April supplement included many informative articles about the Lives Saved Tool (LiST), such as how modelling and calculations are built into the tool, actual calculations of effect sizes in the software and recent applications of various LiST scenarios. We understand that LiST was developed to be used as part of a package of tools for programme managers or ministry of health personnel for planning, helping prioritize investments and evaluating existing programmes.

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. ■