Too Little but Not Too Late: Results of a Literature Review to Improve Routine Immunization Programs in Developing Countries

"Immunization programs need continued support with proven strategies and fresh approaches to reduce the incidence of diseases that may be prevented through the use of traditional vaccines, and to permit the effective introduction of new vaccines."

Research presented in this article describes strategies, including communication strategies, which have been used at the community and/or facility level to strengthen routine immunisation (RI) programmes in developing countries. The researchers conducted a systematic review of studies and projects reported in the published and gray literature; amongst the 11,000 papers they identified, this article summarises the results of 25 papers that met their inclusion criteria (rated based on methodological rigour and data) that were reported to have been successful in improving RI programmes through community- and facility-based interventions over the past 30 years.

One section of the article focuses on strategies for bringing immunisations closer to the community. "The studies included in this category used non-health workers to encourage people to seek immunization services, or increased access to immunization services by bringing services to communities, and additionally in some cases by increasing demand through educating communities." For example, 2 of the 25 studies that met the researchers' criteria for inclusion in this review (see Table 3; footnote numbers have been removed, here) found that: "An observational study in Bangladesh evaluated using semi-literate and illiterate local women in an urban setting to track defaulters using a color-coded tracking system, to refer them to services and accompany mothers to immunization clinics. During the 13-month intervention (1987-1988), 87% percent of children referred by these volunteers completed the recommended immunization series and 96% of women that were referred received tetanus vaccine. A similar program in South Africa evaluated giving record cards to Village Health Workers (VHWs) to record home visits over a one-year period (1988) in an intervention district. VHWs used the cards to identify children to visit, document visit frequency, and track health interventions including immunizations. Sixty-seven percent of children born during the program had completed their third dose of Oral Polio Vaccine (OPV) by eight months of age compared with 50% in the cohort of children (13 to 24 months) born before the program was implemented. However, coverage with measles vaccine by 10 months of age among children aged 13 to 24 months was higher compared to children exposed to the program."

Another section explores the provision of information through numerous channels to either increase awareness of the benefits of immunisation or to promote participation. [Footnote numbers have been removed]. "These strategies increase demand for vaccination without changing the service delivery. Mass communication campaigns have the potential to reach large numbers of people, if access to the type of media selected is good. In the Philippines, a mass media campaign focusing on measles vaccination delivered through routine services was evaluated. An increase in the percentage of FVC [fully vaccinated children] from 54% in 1989 to 65% in 1990 was reported; this increase was attributed to the impact of the media campaign....In the West Bank providing information at the local level through training community members regarding immunizations and providing resource rooms with information on immunization did not increase vaccine coverage, however the timeliness of immunizations, defined as children receiving vaccines at the appropriate age, improved (1985-1996)."

In the conclusion section, the researchers note that: "Much was learned from the 25 papers, such as the use of non-health workers to provide numerous services at the community level. However it was startling to see how few papers were identified and in particular how few were of strong scientific quality. Further well-designed and well-conducted scientific research is warranted. Proposed areas of additional research include integration of additional services with immunization delivery, collaboration of immunization programs with new partners, best approaches to new vaccine introduction, and how to improve service delivery."