The effects and costs of expanding the coverage of immunisation services in developing countries: a systematic literature review
Introduction
Immunization services are one of the most cost-effective ways of reducing child mortality [1]. However, coverage rates of basic vaccines in developing countries are stagnating. While official policy recommendations are for all countries to reach at least 90% coverage with the primary series of three doses of diphtheria–tetanus–pertussis (DTP) vaccine [2], about 20% of the 165 countries with data have never achieved 80% coverage and 10% have never achieved 50% [3]. Therefore, in many countries, there is still scope and the need to increase coverage rates.
The basic vaccination schedule recommended by the World Health Organisation (WHO) is: bacillus Calmette Guerin (BCG) at birth; DTP given together with oral polio vaccine (OPV) at 6, 10 and 14 weeks; and Measles, given at 9 months. A fully vaccinated child (FVC) should have received all these vaccines. However, not all information systems keep data by child. In such cases, vaccination with DTP3 offers a good proxy for full coverage since it implies all the previous vaccines have been taken (or, at least, DTP1 and DTP2 and OPV1 and OPV2) [4].
Little is currently known about the comparative effectiveness and cost-effectiveness of different ways of increasing coverage. Therefore, the aim of this work is to systematically review the published literature on effective and cost-effective ways to expand the coverage of existing child immunisation services in developing countries. The specific objectives were: to describe the available literature about interventions designed to increase coverage; to identify the interventions which can be reliably accepted as effective and cost-effective; and to reflect on the use of such knowledge for local and international decision making. It is hoped that this work will also feed into ongoing discussions regarding the relative merits of adding new vaccines, such as those against Hepatitis B virus (HBV), Haemophilus influenzae type b (Hib) and rotavirus versus increasing coverage rates of existing ones.
Section snippets
Sources of data and search strategy
A review of the literature published up to December 2001 was carried out using major electronic databases: Medline; Popline; BIDS; CAB Abstracts; Web of Science; PubMed; EconLit; HEED; The Cochrane Library; and the WHO regional databases (LILACS, IMSEAR, IMEMR and AIM). The terms “immunisation”, “coverage” and “increasing” were searched in all databases. Synonyms and spelling variants were identified and a mixture of thesaurus (subject indexing) and free-text terms were used. Finally, an
Results
Of the 60 papers selected for inclusion, 52 presented data on effectiveness, seven conducted a cost analysis and three were cost-effectiveness evaluations.2 Fifty-two studies used an ecological design and three were randomised-controlled trials. The majority of ecological studies used single (i.e. only one population group)
Which interventions appear to be the most effective and/or least costly?
With one exception, all interventions were reported to have a positive impact on the proportion of fully vaccinated children. The exception was a mass campaign when evaluated for longer than 1 year. This could be due to their high resource requirements and to the disproportionate attention given to campaigns by donors and ministries, which could disrupt routine services and their long-term results. If this is the case, then mass campaigns may be better used when the local circumstances and
Conclusion
It is difficult to reach any firm conclusion given the quality and paucity of the papers. Accordingly, we suggest transparency to be increased in future studies. Other improvements concern design (longer follow-ups, consideration of confounding factors, analyses of costs alongside effectiveness, inclusion of broader outcomes involving quality of the vaccine delivery). These changes would improve the quality of the results and decision-makers could be more fully informed about the most desirable
Acknowledgements
We gratefully acknowledge the World Health Organisation, Geneva for funding under project reference I8/181/1024. We also thank the following colleagues at the London School of Hygiene and Tropical Medicine: Drs. Alison Rodger, Colin Sanderson, Vivian Valdmanis and John Eyers for their help refining our selection criteria and analysis of strategies. We also thank Ulla Kou at WHO for comments on a draft report. This work is part of a larger project funded by the UK Department of International
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