1. Routine Immunization: The Missed Child Perspective Maya van den Ent, PharmD MPH Edward Hoekstra, MD, MSc David Brown, DSc, MScPH, MSc Halima Dao, MD, MSc Satish Gupta, MD

2. UNICEF Source: WHO/UNICEF immunization coverage for 2010 Coverage MCV1 globally and in 47 priority countries

3. UNICEF 2000 2005 2010 Number of countries (all countries) MCV1 coverage200020052010 <70%373626 70-79%2717 80-89%443124 90-99%84109127 Source: WHO/UNICEF immunization coverage for 2010 MCV1 Coverage 2000 – 2010 47 Priority Countries

4. Human Rights The Universal Declaration of Human Rights: based on the principle of human equality; everyone has right to equal access to public services in his or her country everyone has the right to a standard of living adequate for the health and well being of him/her and family, including food, clothing, housing, medical care and social services.

5. Child Rights Child Rights…. Convention on the Rights of the Child: four core principles: non-discrimination devotion to the best interests of the child the right to life, survival and development respect for the views of the child.

6. The poorest are more likely to die Indonesia Under 5 Mortality Rate by Wealth Quintiles 2002 - 2003

7. Proportion of children under 5 years who are underweight, by household wealth quintile Progress for Children: Achieving the MDGs with Equity ; September 2010; NFHS-2005-06 Level of under - nutrition in children belonging to the poorest households has remained stagnant for decade

8. 19.1 million infants not having received MCV1, 2010 Country Cover age # Infants no MCV1 (routine) India746,709,000 Nigeria711,668,000 DR Congo68815,000 Uganda55630,000 Pakistan86619,000 Indonesia89468,000 Ethiopia81463,000 Afghanistan62458,000 South Africa65352,000 USA92342,000 Every seventh child not reached

9. % based on 887 reasons abstracted from 209 relevant articles Under – vaccinatedUnvaccinated Family Character- istics Immunization Systems Parental Attitudes And Knowledge % based on 33 reasons abstracted from 12 articles on unvaccinated children Under vaccinated: Infants received at least one vaccine, but no DTP3 Un-vaccinated: Infants received no vaccine at all Reasons for under- or un-vaccination

10. Percentage of children age 12-23 fully immunized District Level Household Survey 2007-2008 India: Immunization coverage varies significantly among different population categories among different population categories

11. Source: DLHS 2007-08; children surveyed were between 12-23 months India: Where are the unvaccinated? Children not vaccinated with DPT3

12. Wide intra-state variations Source: DLHS 2007-08; children surveyed were between 12-23 months India: Where are the unvaccinated ? District - level percentage of fully immunized children

13. UNICEF Poor Education Mother no TT2+ Minority religion Rural No Radio/TV Poor Source: Swiss Tropical Institute 2010 India – Predictors Only at least one vaccine vs fully immunized

14. The poorest are more likely not to be immunized

15. Greater disparities between provinces than rural urban

16. UNICEF -Measles Partnership explores ways to further strengthen routine immunization in 2012 -Plan for critical activities strengthening routine during SIA planning How to Reach the Under-served Possible links between SIAs and RI

17. UNICEF Possible links between SIAs and RI Coordination & accountability for results Bottom-up Micro-planning Training Logistics Management Cold chain assessment & maintenance Advocacy and Social Mobilization Evidence based Use of community health workers (defaulter tracing) Health education for caregivers

18. UNICEF Possible links between SIAs and RI AEFI monitoring and management Surveillance Monitoring and Evaluation Supportive supervision Monitoring charts Review meetings feeding into new microplans Rapid assessments

19. Source: Vijayaraghavan M, Health Policy 2006 Nationwide Measles Vaccination Coverage by Wealth Quintile, Kenya, 2002 Measles campaigns reach the poorest Source: Vijayaraghavan M, et al. Health Policy 2007, 83: 27-36

20. MCV1 coverage has steadily improved from 2000 - 2010 19.1 million children remain unreached in 2010 Focus on under- served populations will have highest impact Conclusions Conclusions