Immunization is one of the most cost-effective public health interventions to date, saving millions of lives1 and protecting countless children from illness and disability. As a direct result of immunization, polio is on the verge of eradication. Deaths from measles, a major child killer, declined by 79 per cent worldwide and by 86 per cent in sub-Saharan Africa between 2000 and 2014.2 And as of August 2015, 38 of 59 priority countries have eliminated maternal and neonatal tetanus.
Immunization has not yet realized its full potential, however. As of end-2014, 18.7 million children under 1 year of age worldwide had not received the three recommended doses of diphtheria, tetanus and pertussis containing vaccine (DTPCV3), and 20.6 million children in the same age group had failed to receive a single dose of measles-containing vaccine. Given an estimated annual cohort of 133.9 million surviving infants, an additional 5.3 million children would need to have been reached during 2014 to attain 90% DTPCV3 coverage globally.
Immunization is an affordable means of protecting whole communities from disease and reducing poverty. Immunization coverage for the six major vaccine-preventable diseases – pertussis, childhood tuberculosis, tetanus, polio, measles and diphtheria – has risen significantly since the Expanded Programme on Immunization began in 1974.
An increasing number of countries are now offering pneumococcal conjugate vaccine (127 countries as of September 2015) and rotavirus vaccine (82 countries as of September 2015) in their immunization programmes, thus offering protection against pneumonia and diarrhoea. Use of underutilized vaccines, such as those against yellow fever and Japanese encephalitis, has also been expanded. UNICEF and the World Health Organization (WHO) have broadened their monitoring process accordingly to include coverage of all of these vaccines.
Source: WHO and UNICEF estimates of national immunization coverage, 2014 revision (completed July 2015).
ROUTINE IMMUNIZATION COVERAGE
The percentage of children receiving DTPCV3 is often used as an indicator of how well countries are providing routine immunization services. Global coverage for three doses of DTP-containing vaccine increased from 20 per cent in 1980 to 73 per cent in 2000 to an estimated 86 per cent by the end of 2014.
Despite these advances, many more children could be receiving the benefits of immunization. Of the 18.7 million children worldwide who have not received three doses of DTP-containing vaccine, half live in only five countries. Absolute numbers of unvaccinated infants are highest in the most populous developing countries, some of which enjoy fairly high rates of immunization coverage. Efforts to raise global immunization levels will require a strong focus on the countries where the highest numbers of unvaccinated children live – while also ensuring that the countries where children are most likely to miss out on immunization are not neglected in the search for greater global impact.
Source: WHO and UNICEF estimates of national immunization coverage, 2014 revision (completed July 2015). Population data for children surviving to 1 year of age obtained from: United Nations, Department of Economic and Social Affairs, Population Division, World Population Prospects: The 2012 revision, United Nations, New York, 2013.
THE GOAL: UNIVERSAL ACCESS
The Global Vaccine Action Plan was endorsed by 194 Member States of the World Health Assembly in May 2012 to achieve the vision of universal access to immunization outlined in the Decade of Vaccines. The action plan is a framework to prevent millions of deaths by 2020 and beyond by:
- Strengthening routine immunization to meet vaccination coverage targets
- Accelerating control of vaccine-preventable diseases with polio eradication as the first milestone
- Introducing new and improved vaccines
- Spurring research and development for the next generation of vaccines and technologies.
Progress on the Global Vaccine Action Plan is reported annually to the World Health Assembly and began in 2014.
The Global Vaccine Action Plan builds on the Global Immunization Vision and Strategy 2006─2015, developed by UNICEF, WHO and partners to assist countries in expanding the reach of immunization to every eligible person, including those in age groups beyond infancy. One of its goals is to increase national immunization coverage to at least 90 per cent by 2010 and to sustain such levels through 2015. During 2014, seven of 195 countries had an estimated DTPCV3 coverage less than 50 per cent, while 130 countries achieved at least 90 per cent coverage with three doses of DTP containing vaccine. Of these 130 countries, 110 countries, accounting for around 40 per cent of the global birth cohort in 2014, had sustained DTP3 coverage of at least 90 per cent during the most recent five year period 2010–2014.
Source: WHO and UNICEF estimates of national immunization coverage, 2014 revision (completed July 2015).
For further details on the Global Vaccine Action Plan and current progress, visit the GVAP Secretariat.
Gavi, the Vaccine Alliance (formerly known as the GAVI Alliance and the Global Alliance for Vaccines and Immunization) has developed financial sustainability plans for countries eligible for support. But mobilizing and securing adequate funding will also require stronger political will, better management and greater advocacy.
Increases in routine coverage and improved availability of new vaccines can succeed in reducing child deaths, even in the poorest countries and under difficult circumstances. Strategies to reach every district include re-establishing outreach services, building district-level micro-planning, providing supportive supervision and linking communities with services.
Campaigns such as those for polio eradication and measles mortality reduction have helped strengthen the cold chain and injection safety. Support from Gavi for the introduction of new vaccines, including training, demand-creation and cold-chain expansion, is helping boost immunization activities.
Greater attention is also being focused on improving the availability, retention and utilization of home-based vaccination records (vaccination cards). Such records play an important role in documenting immunization services received by individuals (1). When properly used, they provide a relatively inexpensive and effective instrument for promoting childhood immunization, educating caregivers about their child’s immunization status and stimulating demand for services. UNICEF and WHO in collaboration with partners are working with national immunization programmes to improve the availability, utilization and retention of home-based records. An online library, www.immunizationcards.org, has been established to facilitate review and exchange of information on existing vaccination and child health cards, and a website has been developed to monitor their prevalence through household surveys. The WHO has also developed a Practical Guide for the Design, Use and Promotion of Home-Based Records in Immunization.
- Levine, O.S., et al., ‘The Future of Immunisation Policy, Implementation, and Financing’, Lancet, vol. 378, 2011, pp. 439─448.
- Perry, R., et al., “Progress towards regional measles elimination, worldwide, 2000–2014”, Weekly Epidemiological Record, No. 46, 13 November 2015, pp. 623-631
Results from a survey of national immunization programmes on home-based vaccination record practices in 2013
During January 2014, WHO and the United Nations Children's Fund sent a one-page questionnaire to 195 countries to obtain information on HBRs including type of record used, number of records printed, whether records were provided free-of-charge or required by schools, whether there was a stock-out and the duration of any stock-outs that occurred, as well as the total expenditure for printing HBRs during 2013.
Home-based record prevalence among children aged 12-23 months from 180 demographic and health surveys
There is currently a re-focus at the global level on the importance of the home-based record within vaccination service delivery as an important information resource but there are few reports of ever and current home-based record prevalence across countries. We considered all Demographic and Health Surveys (starting with DHS round 3) conducted between 1993 and 2013 for which a final dataset was available in the public domain at the time of the analysis.
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In 1974, WHO established the Expanded Programme on Immunization to ensure that all children have access to routinely recommended vaccines. Since then, global coverage with the 4 core vaccines – Bacille Calmette-Guérin vaccine (BCG) for protection against tuberculosis, diphtheria-tetanus-pertussis vaccine (DTP), polio vaccine, and measles vaccine – has increased from <5% to ≥85%, and additional vaccines have been added to the recommended schedule. Estimated global coverage with the third dose of DTP vaccine (DTP3) has remained at 84%–86% since 2009, with estimated 2014 coverage at 86%. Estimated global coverage for the second routine dose of measles-containing vaccine (MCV2) was 38% by the end of the second year of life and 56% when including older age groups. Improvements in equity of access and use of immunization services will help ensure that all children are protected from vaccine-preventable diseases.
Subaiya S, Dumolard L, Lydon P, Gacic-Dobo M, Eggers R and Conklin L. Global Routine Vaccination Coverage, 2014. Weekly epidemiological record, No. 46, 13 November 2015, p.617.
Country-specific reports of the WHO and UNICEF estimates of national immunization coverage
The graphs and data tables displayed in the country-specific reports show the national coverage levels for each vaccine for the period from 2003 through 2014 (see guide
To access country data please click on country name
Central and Eastern Europe and the Commonwealth of Independent States
East Asia and the Pacific
Eastern and Southern Africa
Latin America and the Caribbean
Middle East and North Africa
West and Central Africa
Since June 2000, WHO and UNICEF have conducted annual reviews of national immunization coverage. Immunization coverage estimates are used for a variety of purposes: to monitor the performance of immunization services at local, national and international levels; to guide polio eradication, measles control and maternal and neonatal tetanus elimination; to identify areas of weak system performance that may require extra resources and focused attention; and as one indicator when deciding whether to introduce a new vaccine. Coverage levels with diphtheria-tetanus-pertussis-containing vaccine (DTP) are considered one indicator of health system performance.
A detailed explanation of the methods behind the WHO and UNICEF estimates of national immunization coverage is provided elsewhere.1,2,3,4 Estimates of immunization coverage are generally based on two sources of empirical data: reports of vaccinations performed by service providers (administrative data5) and household surveys containing items on children's vaccination history (coverage surveys). For estimates based on administrative data, the immunization coverage is derived by dividing the total number of vaccinations given by the number of children in the target population. For most vaccines the target population is the national annual number of births or number of surviving infants (this may vary depending on countries' policies and the specific vaccine). Immunization coverage surveys are frequently used in connection with administrative data. The World Health Organization’s Vaccination Coverage Cluster Survey, which is now preferred to the Expanded Programme on Immunization (EPI) 30-cluster survey; the UNICEF-supported Multiple Indicator Cluster Surveys (MICS) and the Demographic Health Surveys (DHS) supported by the United States Agency for International Development are the principal surveys used as sources of information on immunization coverage.
This review relies on the following data:
- Officially reported data by WHO and UNICEF Member States
- A historical database maintained by UNICEF
- Nationally representative, population-based household survey reports (published and unpublished).
It is important to distinguish whether data accurately reflect immunization system performance or whether they are compromised and thus present a misleading view of immunization coverage. Officially reported data are therefore compared with independent surveys. Based on the data available, the consideration of potential biases and the contributions of local experts, the most likely level of immunization coverage is determined for each country–year–antigen combination. An essential part of this review is consultation and collaboration with national authorities, who are asked to review the draft estimates and provide comments.
- Burton, A., et al., ’A Formal Representation of the WHO and UNICEF Estimates of National Immunization Coverage: A computational logic approach’, PLOS ONE, vol. 7, no. 10:e47806, 2012.
- Kowalski R., A. Burton, ’WUENIC – A Case Study in Rule-based Knowledge Representation and Reasoning’, Lecture Notes in Computer Science, vol. 7258, 2012, pp. 112─125.
- Burton, A., et al., WHO and UNICEF Estimates of National Infant Immunization Coverage: Methods and processes, Bulletin of the World Health Organization, vol. 87, 2009, pp. 535─541.
- Brown DW, Burton AH, Gacic-Dobo M, Karimov RI. An Introduction to the Grade of Confidence Used to Characterize Uncertainty Around the WHO and UNICEF Estimates of National Immunization Coverage. Open Public Hlth J. 2013;6:73-76.
- Administrative data are collected through the WHO/UNICEF Joint Reporting Form on Vaccine-Preventable Diseases, completed annually by countries.
ImmunizationInfo: Expanding access to national immunization coverage estimates
The data above can also be viewed through ImmunizationInfo, an interactive online dissemination tool of national childhood immunization coverage statistics developed in 2010 by UNICEF and WHO in collaboration with Community Systems Foundation. ImmunizationInfo is powered by DevInfo database technology and built using Adobe-Flex. It allows users to view national immunization coverage estimates in graph, map and table formats based on a user-defined selection of country-year-vaccine combinations. Users can generate comparative graphs and also download the underlying data.