Childhood immunisation in South Asia - overcoming the hurdles to progress.

Abstract

ImmunIsatIon In south asIaThe countries of South Asiai have made impressive progress in reducing child mortality. Between 1990 and 2015, the number of under-five deaths per 1,000 live births fell from 129 to 53.1 Despite this progress, almost two million children under five years of age will die in South Asia in 2016. Many (51.8%) of the under-five deaths worldwide (6.3 million) in 2013 were from infectious diseases, many that could be preventable through vaccination.2,3Immunisation is a core intervention to reduce child mortality. It is highly cost-effective4 and globally averts an estimated 2.5 million child deaths every year.5 Most South Asian countries started routinely immunising children in the 1980s with the introduction of the standardised schedule for the Expanded Program on Immunization (EPI).6 In 1980, no country in South Asia other than Sri Lanka was reaching more than 10% of surviving children with a third dose of the diphtheria-tetanus-pertussis (DTP3) vaccine. It is a remarkable achievement that all countries had coverage above 60% by 2007 (Figure 1). However, in 2012, 8 million of the world's 23 million under-immunisedii children lived in South Asia,7 most of them in India, Pakistan, and Afghanistan. The region as a whole is still faring relatively poorly with 76% coverage of DTP3 in 2012 (Figure 2).8 Progress is also starting to show a trend towards stagnation, indicating that increased focus on immunisation and new approaches are needed.In 2012, the Global Vaccine Action Plan (GVAP) 2011-2020 was adopted by the World Health Assembly. GVAP acknowledged that in order to maximise the benefits of vaccination, immunisation programmes should aim to extend DTP3 coverage to 90% in every country by 2015, with each district having at least 80% coverage, and targeting children from the most disadvantaged communities.9 South Asia lags behind both this coverage and equity goal. For example, in Afghanistan's Farah Province, immunisation coverage is less than 3%,10 whereas in Rajshahi district in Bangladesh it is 99%.11BarrIers PreventIng ProgressMany of the challenges for improving immunisation coverage are common to the countries of South Asia. Global funding for immunisation has been extensive with Gavi, The Vaccine Alliance committing almost US$10 billion worth of funding between 2000 and 2020.12 Yet, countries in South Asia have not followed this lead to prioritise their own resources for health. Spending on health is low in many countries of the region,13 and spending priorities affect vaccination programmes. Scarce or poorly maintained refrigeration infrastructure is an issue, as it is globally.14,15 Human resource capacity for effective vaccine delivery is insufficient in many areas, particularly at community level.Other hurdles include difficulties in accurately forecasting demand for vaccination as population data are often of poor quality or outdated. High-quality data are critical to identifying children who have not been vaccinated, reaching those who have 'dropped out' between doses and getting the right number of vaccines to the right place at the right time.16 The completeness of information systems for immunisation is affected by various factors such as increased mobility of individuals, fragmentation of vaccine delivery systems, and outdated recording and reporting formats. In Pakistan, for example, the last national census was in 1993.17Low demand for vaccination among caregivers is another bottleneck. Traditionally, the focus of immunisation programmes has been on raising caregiver awareness and preventing refusal of vaccination. However, it has been suggested that outright opposition to vaccination is becoming a marginal phenomenon and is being replaced by 'vaccination hesitancy', in which caregivers rationally balance arguments for and against vaccination.18 This is consistent with the experience in South Asia. In India, the reasons that caregivers most often give for non-participation in routine immunisation is that the need is not obvious and that they do not know enough about the vaccines. …