Academic journal article Bulletin of the World Health Organization

Studies of Missed Opportunities for Immunization in Developing and Industrialized Countries

Academic journal article Bulletin of the World Health Organization

Studies of Missed Opportunities for Immunization in Developing and Industrialized Countries

Article excerpt


Based on information reported to the World Health Organization (WHO) as of September 1992, global immunization coverage for children by their first birthday was 85% for BCG (Bacille Calmette-Guerin) vaccine, 79% for three doses of diphtheriapertussis-tetanus (DPT) vaccine, 81% for three doses of poliomyelitis vaccine, and 78% for measles vaccine. However, for pregnant women in developing countries, coverage was only 42% for two doses of tetanus toxoid. WHO estimates that in 1991 immunization prevented some 3 million deaths from measles, neonatal tetanus and pertussis, and some 530 000 cases of paralytic poliomyelitis. Additional efforts will be necessary to sustain this progress and to achieve, by the year 2000, the goal of fully immunizing 90% of the world's children by their first birthday. Perhaps the greatest challenge will be to raise the tetanus toxoid coverage of women to the same levels seen for children.

A direct approach to increasing immunization coverage is to provide immunization to all eligible persons at every opportunity. The strategy of immunizing at ever opportunity has been recommended by the Global Advisory Group of the WHO Expanded Programme on Immunization (EPI) since 1983 [1]. Immunizations should be offered at every contact point, including preventive and curative health services. Countries should review national immunization policy and remove excessive contraindications. Children suffering from malnutrition and minor illness are at particular risk for vaccine-preventable diseases and should be immunized.

An opportunity for immunization is missed when a person who is eligible for immunization and who has no contraindication to immunization visits a health service and does not receive all the needed vaccines.

Missed opportunities for immunization occur in two major settings: (1) during visits for immunization and other preventive services (e.g., growth monitoring, nutrition assessments, and oral rehydration training sessions) and (2) during visits for curative services. In both settings, eliminating missed opportunities will raise the overall immunization coverage in a population, particularly when the availability and use of health services are high. When the availability and use of health services are low, immunizing at every health care contact is extremely important because the risk for vaccine-preventable diseases is likely to be high in these areas.

Since 1984, EPI has been promoting the use of a standard survey for assessing missed opportunities for immunization. In 1987, when the results from several surveys in developing countries indicated that the majority of children attending curative care facilities were missing opportunities to be immunized, the Global Advisory Group called for more surveys to investigate the magnitude of the problem among children and women of childbearing age and to identify strategies to reduce missed opportunities (2).

This review of 79 studies on missed opportunities from 45 countries provides information on their global magnitude, the demographic differences, and the reasons for failure to immunize during visits to the health services. Strategies to reduce missed opportunities are recommended, which emphasize the usefulness of periodic systematic monitoring to evaluate the quality of immunization programme performance at the health service level as well as progress towards reducing missed opportunities.


Criteria for inclusion of studies

Only studies that assessed missed opportunities for immunization in the EPI target groups (children and women of childbearing age) were included. We reviewed studies reported in the world literature on missed opportunities for immunization or failure to vaccinate and unpublished studies reported to WHO up to JUly 1991. The review considered only studies that defined a missed opportunity for immunization as any contact with a health service that did not result in an eligible child or woman receiving all the needed vaccines. …

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