VACCINATIONS FOR TRAVELLERS ABROAD

Vaccinations for travellers abroad 

Where further advice is required

Speak to your GP before having any vaccinations if:

• you are pregnant
• you are breastfeeding
• you have an immune deficiency
• you have any allergies

Travel vaccines information

Read more about the vaccines used to protect people travelling abroad

The following vaccinations are available for people travelling abroad:

• cholera
• diphtheria
• hepatitis A
• hepatitis B
• Japanese encephalitis
• meningococcal meningitis
• MMR (measles, mumps and rubella)
• polio
• rabies
• tetanus
• tick-borne encephalitis
• tuberculosis (TB)
• typhoid
• yellow fever

Cholera vaccination

Vaccination against cholera is recommended for travellers to areas where the infection is widespread, particularly for aid workers and people likely to have limited access to medical services.

Most cases of cholera are confined to regions of the world with poor sanitation and water hygiene, such as parts of sub-Saharan Africa, the Indian subcontinent, South East Asia, the Middle East and South America.

The vaccine is usually given as a drink in two separate doses, taken one to six weeks apart (children aged two to six should have a third dose taken one to six weeks after the second dose). You should make sure you have the final dose of this vaccine at least a week before you travel.

A single booster dose or full re-vaccination is usually recommended if you have previously been vaccinated against cholera and you are planning to travel to an area where the infection is common.

Read more about the cholera vaccine.

Diphtheria vaccination

A combined vaccination that protects against diphtheria, polio and tetanus is routinely given to all children in the UK. You should ensure you and your children are up to date with your routine vaccinations before you travel.

Further booster doses are usually only recommended if you're going to visit parts of the world where diphtheria is widespread and your last vaccination dose was more than 10 years ago.

Areas with high rates of diphtheria include sub-Saharan Africa, South East Asia, South America and the Indian subcontinent.

Additional doses of the vaccination are given in a single 3-in-1 Td/IPV (tetanus, diphtheria and polio) injection.

Read more about the diphtheria travel vaccine.

Hepatitis A vaccination

Vaccination against hepatitis A is recommended if you're travelling to countries where hepatitis A is widespread, particularly if you are staying for a prolonged period or you are staying somewhere with poor levels of sanitation and hygiene.

Areas with a high risk of hepatitis A include Africa, the Far East, eastern Europe and the Indian subcontinent.

The vaccination against hepatitis A is usually given as a single initial injection, with an optional booster dose 6-12 months later that can protect you for at least 20 years if necessary. 

You should preferably have this initial dose at least two weeks before you leave, although it can be given up to the day of your departure if needed.

Jabs that offer combined protection against hepatitis A and hepatitis B or typhoid are also available if you are likely to also be at risk of these conditions.

Read more about the hepatitis A vaccine.

Hepatitis B vaccination

Vaccination against hepatitis B is recommended if you're travelling in parts of the world where hepatitis B is common, especially if you will be doing activities that increase your risk of developing the infection.

As hepatitis B is spread through blood and body fluids, activities such as having sex, injecting drugs or playing contact sports on your travels can increase your risk. Anyone travelling for long periods or who is likely to need medical care while abroad is also at increased risk. 

Hepatitis B is found worldwide, but it's more common in sub-Saharan Africa, most of Asia, the Pacific islands, parts of South America, southern parts of Eastern and Central Europe, the Middle East and the Indian subcontinent.

The hepatitis B vaccination generally involves a course of three injections. Depending on how quickly you need protection, these may be spread over a period as long as six months or as short as three weeks.

A combined hepatitis A and hepatitis B jab is also available if you are likely to be at risk of both these conditions while travelling.

Read more about the hepatitis B vaccine.

Japanese encephalitis vaccination

Vaccination against Japanese encephalitis is usually recommended if you're planning an extended stay (usually at least a month) in a country where the condition is widespread.

It's particularly important if you are visiting during the rainy season, if you are going to visit rural areas (such as rice fields or marshlands), or you will be taking part in any activities that may increase your risk of becoming infected (such as cycling or camping).

Japanese encephalitis is present across huge areas of Asia, stretching from the Pacific islands in the east to the borders of Pakistan in the west. It is found as far north as Korea and as far south as Papua New Guinea.

Vaccination against Japanese encephalitis usually consists of two injections, with the second dose given 28 days after the first. Ideally, you need to have the second dose a month before you leave.

Read more about the Japanese encephalitis vaccine.

Meningococcal meningitis vaccination

Vaccination against meningococcal meningitis is usually recommended if you're travelling to areas at risk and your planned activities put you at higher risk, for example if you're a long-term traveller who has close contact with the local population.

High-risk areas for meningococcal meningitis include parts of Africa and Saudi Arabia. All travellers to Saudi Arabia for the Hajj or Umrah pilgrimages are required to show proof of vaccination.

If travelling to a high-risk area, you should be vaccinated against meningococcal meningitis with an ACWY vaccine (also known as the quadrivalent meningococcal meningitis vaccine). This is given as a single injection and it should be given two to three weeks before you travel.

You should have the ACWY vaccine before travelling to high-risk areas even if you had the meningitis C vaccine as a child.

Read more about the meningococcal meningitis vaccine.

MMR (measles, mumps and rubella) vaccination

The MMR vaccine that protects against measles, mumpsand rubella is routinely given to all children in the UK. You should ensure you and your children are up to date with your routine vaccinations before you travel.

If you've not been fully vaccinated against these conditions or you're not already immune, the MMR vaccination is recommended before travelling to areas where these conditions are widespread or where there has been a recent outbreak.

The MMR vaccine is given as two injections. These are usually given when a child is 12-13 months old and when they start school. However, adults can have the two doses one month apart and children can have them three months apart if necessary.

You should ideally have the final dose at least two weeks before you leave.

Read more about the MMR vaccine.

Polio vaccination

A combined vaccination that protects against diphtheria, polio and tetanus is routinely given to all children in the UK. You should ensure you and your children are up to date with your routine vaccinations before you travel.

Further booster doses are usually only recommended if you're going to visit parts of the world where polio is widespread and your last vaccination dose was more than 10 years ago.

Currently, the condition is most common in Pakistan, Afghanistan and Nigeria, but it's also a risk in other regions of the world.

Additional doses of the vaccination are given in a single 3-in-1 Td/IPV (tetanus, diphtheria and polio) injection.

Read more about the 3-in-1 Td/IPV vaccine.

Rabies vaccination

Vaccination against rabies is advised if you're travelling to an area where rabies is common in animals, particularly if you are staying for a month or more, there is limited access to medical services and you will be carrying out activities that could expose you to rabies (such as cycling or running).

Rabies can be found in many parts of the world, including the Middle East, Africa, Asia, Central and South America, and some parts of Eastern Europe.

Vaccination usually requires a course of three injections. The second dose is given seven days after the first and the third dose is given 14-21 days after the second.

Further doses are not usually recommended for travellers, unless it has been more than 10 years since you were first vaccinated and you are visiting an area with a high risk of rabies.

Read more about the rabies vaccine.

Tetanus vaccination

A combined vaccination that protects against diphtheria, polio and tetanus is routinely given to all children in the UK. You should ensure you and your children are up to date with your routine vaccinations before you travel.

Further booster doses are usually only recommended if you're travelling to areas where access to medical services is likely to be limited or your last vaccination dose was more than 10 years ago.

Additional doses of the vaccination are given in a single 3-in-1 Td/IPV (tetanus, diphtheria and polio) injection.

Read more about the 3-in-1 Td/IPV vaccine.

Tick-borne encephalitis vaccination

Vaccination against tick-borne encephalitis (TBE) is usually recommended for anyone who plans to live or work in a high-risk area, or hike and camp in these areas during late spring or summer.

The ticks that cause TBE are mainly found in forested areas of central, eastern and northern Europe, although at-risk areas also include eastern Russia and some countries in East Asia (particularly forested regions of China and Japan).

The vaccination requires a course of three injections for full protection. The second dose is given one to three months after the first and provides immunity for about one year. A third dose, given 5-12 months after the second, provides immunity for up to three years.

The course can sometimes be accelerated if necessary. This involves two doses being given two weeks apart.

Booster doses of the vaccine are recommended every three years if necessary.

Read more about the tick-borne encephalitis vaccine.

Tuberculosis (TB) vaccination

Vaccination against tuberculosis (TB) is given to some children in the UK who are at increased risk from tuberculosis.

For travellers, the BCG vaccination (which protects against TB) is recommended for people under 16 years old who will be living or working with local people for three months or more and have not been previously vaccinated.

Parts of the world that have high rates of TB include sub-Saharan and west Africa, South East Asia, Russia, China, South America and the western Pacific region.

The BCG vaccine is given as a single injection.

Read more about the BCG vaccine.

Typhoid vaccination

Vaccination against typhoid fever is recommended if you are travelling to parts of the world where the condition is common, particularly if you will be staying or working with local people or you will have frequent or prolonged exposure to conditions where sanitation and food hygiene are likely to be poor.

High-risk areas include parts of Africa, Central America, the Indian subcontinent, the Middle East, South America and South and South East Asia.

Two main vaccines are available for typhoid fever in the UK. One is given as a single injection and one is given as three capsules to take on alternate days. It is also possible to have a combined hepatitis A and typhoid jab.

Ideally, the typhoid vaccine should be given at least one month before you travel, but it can be given closer to your travel date if necessary.

The protective effect of the injectable vaccine lasts about three years. After that time, another injection is necessary. The long term protection after a booster dose is not known.

A booster dose is recommended one year after the oral vaccine unless you remain in an area of risk, when a boost at three years may be sufficient.

Read more about the typhoid vaccine.

Yellow fever vaccination

Vaccination against yellow fever is advised if you're travelling to areas where there's a risk of yellow fever transmission. Some countries require proof of vaccination certificate before they let you enter the country.

Yellow fever is most common in some areas of tropical Africa and South America.

A booster dose of the yellow fever vaccine is currently recommended every 10 years if you are still at risk. However, this is likely to change in the future as recent evidence suggests that a single dose offers life-long protection.

You must have a yellow fever vaccination at least 10 days before you travel.

Read more about the yellow fever vaccine.

VACCINES (IMMUNIZATIONS)

Vaccines (immunizations) - overview

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Vaccines are used to improve your immune system and prevent serious, life-threatening diseases.

Information

HOW VACCINES WORK

Vaccines "teach" your body how to defend itself when germs, such as viruses or bacteria, invade it:

• They expose you to a very small, very safe amount of viruses or bacteria that have been weakened or killed.
• Your immune system then learns to recognize and attack the infection if you are exposed to it later in life.
• As a result, you will not become ill or you may have a milder infection. This is a natural way to deal with infectious diseases.

Four types of vaccines are currently available:

• Live virus vaccines use the weakened (or attenuated) form of the virus. The measles, mumps, and rubella (MMR) vaccine and the varicella (chickenpox) vaccine are examples.
• Killed (inactivated) vaccines are made from a protein or other small pieces taken from a virus or bacteria. The flu vaccine is an example.
• Toxoid vaccines contain a toxin or chemical made by the bacteria or virus. They make you immune to the harmful effects of the infection, instead of to the infection itself. Examples are the diphtheria and tetanus vaccines.
• Biosynthetic vaccines contain manmade substances that are very similar to pieces of the virus or bacteria. The Hib (Haemophilus influenzae type B) conjugate vaccine is an example.

WHY WE NEED VACCINES

For a few weeks after they are born, babies have some protection from germs that cause diseases. This protection is passed from their mother through the placenta before birth. After a short period, this natural protection goes away.

Vaccines help protect against many diseases that used to be much more common. Examples include tetanus, diphtheria, mumps, measles, pertussis (whooping cough), meningitis, and polio. Many of these infections can cause serious or life-threatening illnesses and may lead to lifelong disabilities. Because of vaccines, many of these illnesses are now rare.

SAFETY OF VACCINES

Some people worry that vaccines are not safe and may be harmful, especially for children. They may ask their health care provider to wait or even choose not to have the vaccine. But the benefits of vaccines far outweigh their risks.

Scientific studies have shown that vaccines and their components, such as the preservative thimerosal, do not cause autism or ADHD. Based on these studies, the American Academy of Pediatrics, the Centers for Disease Control and Prevention, as well as the Institute of Medicine conclude that the benefits of vaccines outweigh their risks.

Other information about risks:

• Getting the actual infection from vaccines: Unless a person's immune system is weakened, it is unlikely that a vaccine will give the person the infection. Vaccines, such as the measles, mumps, rubella, the chickenpox, and nasal spray flu contain live but weakened viruses and should not be received by persons with weakened immune systems.
• Allergic reactions: Such reactions are rare and are usually to some part (component) of the vaccine. 
• Danger of live vaccines: Certain live vaccines may be dangerous to the fetus of a pregnant woman. These include the measles, mumps, rubella vaccine, the chickenpox vaccine, and the nasal spray flu vaccine. To avoid harm to the baby, pregnant women should not receive any of these vaccines. The health care provider can tell you the right time to get these vaccines.

VACCINE SCHEDULE

The recommended vaccination (immunization) schedule is updated every 12 months by the U.S. Centers for Disease Control and Prevention (CDC). Talk to your health care provider about specific immunizations for you or your child. Current recommendations are available at the CDC website: http://www.cdc.gov/vaccines/schedules.

TRAVELERS

The CDC website (http://www.cdc.gov/travel/page/vaccinations.htm) has detailed information on immunizations and other precautions for travelers to other countries. Many immunizations should be received at least one month before travel.

Bring your immunization records with you when you travel internationally. Some countries require this documentation.

TETANUS TOXOID (TT) DURING PREGNANCY

The Tetanus Toxoid (TT) vaccine is given during your pregnancy to prevent tetanus to you as well as your baby. AntTetanus is a life-threatening bacterial disease that is caused by the toxin of a bacterium called Clostridium tetani. Tetanus bacteria enter the body through an open wound. It could well be a tiny prick or scratch on the skin, although Tetanus infection is more common when there is a deep puncture wound such as a bite, cut, burn or an ulcer. Tetanus affects a person’s nervous system and can be fatal if left untreated. It is preventable through immunisation.

ibodies formed in your body, after the vaccination, are passed on to your baby and protect her for a few months after birth. It also helps prevent premature delivery. 

In the first pregnancy, your doctor will recommend at least two doses of the TT vaccine. The first vaccination is given in the first trimester soon after your pregnancy tests are confirmed and after your first antenatal appointment. The second dose of the TT vaccine is given at least four to eight weeks after the first. Some experts recommend that the second dose of the vaccine should be given four weeks prior to the expected date of delivery. The WHO also recommends that a third vaccine be given six months after the second one to provide protection for at least five years. 

If this is your second pregnancy and it has been less than two years since your last pregnancy, when you had received both TT vaccines, then only a booster dose is recommended. In many countries such as the US, the Td or tetanus-diphtheria vaccine is recommended for pregnant women. This vaccine is now available in India. You may want to check with your doctor if she would like you to opt for it. 

Rubella

Centers for Disease Control and Prevention

Boy with rubella rash

Symptoms and Causative Agent

Rubella is caused by a virus from the genusRubivirus. Its symptoms include low-grade fever, respiratory problems, and most notably a rash of pink or light red spots that typically begins on the face and spreads downward. The rash occurs about two to three weeks after exposure to the virus.

In children, illness from rubella infection is usually mild. Complications from rubella are more common in adults than children, and include arthritis, encephalitis, and neuritis.

A woman who contracts rubella infection during pregnancy can pass the infection to the developing fetus. Such pregnancies are at risk of spontaneous abortion or premature birth. If the fetus survives, the child may suffer from a wide range of birth defects, including deafness, eye defects, cardiac defects, mental retardation, bone lesions, and other abnormalities. Together, the defects are known as Congenital Rubella Syndrome (CRS). Of children whose mothers are infected during their first trimester of pregnancy, studies suggest that between 50% and 90% will suffer from CRS.

Although rubella is sometimes called “German measles,” the rubella virus is not related to the measles virus.

Transmission

The virus is spread by airborne respiratory droplets. Infected individuals may be contagious as early as a week before the appearance of the rubella rash, and for up to a week after it first appears. (It is most contagious at the time the rash first appears.) Children born with CRS may transmit the virus to others for more than a year.

Rubella cases typically peak in late winter or early spring.

Treatment and Care

There is no direct treatment for rubella. Supportive care may be provided, including efforts to lower fever.

Complications

Rubella is not normally a serious illness in children, and, in fact, its symptoms are often mild. The chief danger of the disease is Congenital Rubella Syndrome.

From 1964-1965, before the development of a vaccine against the disease, a rubella epidemic swept the United States. During that short period there were 12.5 million cases of rubella. Twenty thousand children were born with CRS: 11,000 were deaf, 3,500 blind, and 1,800 mentally retarded. There were 2,100 neonatal deaths and more than 11,000 abortions – some a spontaneous result of rubella infection in the mother, and others performed surgically after women were informed of the serious risks of rubella exposure during their pregnancy.

As of 2004, rubella was declared eliminated in the United States, and transmission of the rubella virus in the World Health Organization’s Region of the Americas was halted in 2009. Globally, about 100,000 rubella cases were reported for 2012 in the member states to the World Health Organization, though it is probable that the number of actual cases is much higher. The countries with the largest number of cases in 2012 were Timor-Leste, Macedonia, Thailand, Tajikistan, and Syria.  The number of estimated CRS cases each year is more than 100,000.

Available Vaccines and Vaccination Campaigns

The first rubella vaccine—a live, attenuated vaccine—was licensed in 1969. It was developed by the prolific vaccine researcher Maurice Hilleman, using rubella virus obtained from Division of Biologics Standards scientists Paul Parkman and Harry Meyer. Other companies in both the United States and Europe licensed their own rubella vaccines. Hilleman’s rubella vaccine was used in the combination measles-mumps-rubella (MMR) vaccine, which was licensed in 1971.

In 1979, an improved live rubella vaccine superseded Hilleman’s in the United States. Developed by Stanley A. Plotkin, MD, the RA27/3 vaccine had been used in Europe for years and offered superior protection against the disease. It also replaced the original rubella vaccine in the MMR combined shot, and is still used today.

Rubella-containing vaccine (RCV) is part of the national immunization program in the Russian Federation, most of Europe, China and a few other countries in Asia, Australia, all of North and South America, and a few countries in Africa. As of 2010, 131 countries, representing 42% of the global birth cohort, use rubella-containing vaccines in their national immunization programs. The World Health Organization encourages countries not currently using rubella vaccination to take advantage of widespread measles vaccination initiatives to introduce RCVs in order to advance rubella and CRS elimination.

U.S. Vaccination Recommendations

Vaccination against rubella is included on the U.S. childhood immunization schedule as part of the combined MMR vaccination. This vaccine is given in two doses, the first at 12-15 months of age and the second between 4-6 years of age. Alternatively, rubella vaccination is available as part of the newer MMRV (measles, mumps, rubella, and varicella) combination vaccine, which also protects against chickenpox.

Women in the United States who are considering becoming pregnant may be tested for rubella immunity, especially if they were born in countries where rubella vaccination is not routinely performed. For women who may become pregnant, only documentation of sufficient vaccination or a positive blood test for rubella antibodies is considered evidence of rubella immunity. If immunity cannot be established, vaccination may be recommended for women considering becoming pregnant. (Rubella vaccination is not indicated for women who are already pregnant, or who intend to become pregnant within four weeks’ time, although CRS has never been reported to be caused by the vaccine.)

VACCINATION DURING PREGNANCY

Why is vaccination necessary?

Vaccines strengthen people’s immune systems so their bodies can fight off serious infectious diseases. Vaccines also benefit society by preventing the spread of communicable diseases.

Why do pregnant women need to be vaccinated?

Many women might not realize they are not up-to-date on their immunizations and are susceptible to diseases that can harm them or their unborn child. Pregnant women should talk to their physicians to figure out which vaccines they might need and whether they should get them during pregnancy or wait until after their child is born.

How do I know if a vaccine’s ingredients are safe?

All vaccines are tested for safety under the supervision of the Food and Drug Administration (FDA). The vaccines are checked for purity, potency, and safety, and the FDA and Centers for Disease Control and Prevention (CDC) monitor the safety of each vaccine for as long as it is in use. Some people might be allergic to an ingredient in a vaccine, such as eggs in the influenza vaccine, and should not receive the vaccine until they have talked to their doctors.

Can a vaccine harm my unborn child?

A number of vaccines, especially live-virus vaccines, should not be give to pregnant women because they might be harmful to the baby. (A live-virus vaccine is made using the live strains of a virus.) Some vaccines can be given to the mother in the second or third trimester of pregnancy, while others should only be administered either at least three months before or immediately after the baby is born.

What happens if I am exposed to a disease while I am pregnant?

Depending on the circumstances, your doctor will weigh the risks of vaccination against the benefits the vaccine can provide.

Which vaccines can I receive while I am pregnant?

The following vaccines are considered safe to give to women who might be at risk of infection:

• Hepatitis B — Pregnant women who are at high risk for this disease and have tested negative for the virus can receive this vaccine. It is used to protect the mother and baby against infection both before and after delivery.
• Influenza — This vaccine can prevent serious illness in the mother during pregnancy. You can receive the vaccine at any stage of your pregnancy.
• Tetanus/Diphtheria — This combination of vaccines is routinely recommended for pregnant women, both those who have never been immunized and those who have not received a booster in 10 years. We usually only give this in pregnancy when there has been trauma. If it has been more than 2 years since the last dT, you will be offered dTaP after pregnancy.

Which vaccines should pregnant women avoid?

The following vaccines can potentially be transmitted to the unborn child and might result in miscarriage, premature birth, or birth defects:

• dTaP — The safety of this vaccine has not been determined. We recommend vaccination after pregnancy.
• Hepatitis A — The safety of this vaccine hasn’t been determined and it should be avoided during pregnancy. Women at high risk for exposure to this virus should discuss the risks and benefits with their doctors.
• Measles, Mumps, Rubella (MMR) — Women should wait at least one month to become pregnant after receiving these live-virus vaccines. If the initial rubella test shows you are rubella non-immune, then you will be given the vaccine after delivery.
• Varicella — This vaccine, used to prevent chicken pox, should be given at least one month before pregnancy.
• Pneumococcal — Because the safety of this vaccine is unknown, it should be avoided in pregnancy except for women who are at high risk or have a chronic illness.
• Oral Polio Vaccine (OPV) and Inactivated Polio Vaccine (IPV) — Neither the live-virus (OPV) nor the inactivated-virus (IPV) version of this vaccine is recommended for pregnant women. Also, the risk of getting polio in the United States is very low.

What side effects can I expect after a vaccination?

Side effects vary from none to those that can occur up to three weeks after vaccination.

If you experience any severe side effects, be sure to tell your doctor.

• Hepatitis A — Soreness and redness at injection site, headache, fatigue, severe allergic reaction in very rare cases
• Hepatitis B — Soreness at injection site, fever
• Influenza — Redness and swelling at injection site that can last up to two days, fever
• Tetanus/Diphtheria — Low-grade fever, soreness and swelling at injection site
• dTaP — Fever, soreness, and swelling at the injection site
• Measles, Mumps, Rubella (MMR) — Non-contagious rash, swelling of neck glands and cheeks, pain and stiffness of joints one to two weeks after vaccination
• Varicella — Fever, soreness or redness at injection site, rash or small bumps up to three weeks after vaccination
• Pneumococcal — Fever, soreness at injection site
• Inactivated Polio Vaccine (IPV) — Redness, discomfort at injection site

EXPANDED PROGRAM ON IMMUNIZATION

The Expanded Program on Immunization is a World Health Organization program with the goal to make vaccines available to all children throughout the world.

HISTORY 

The World Health Organization (WHO) initiated the Expanded Program on Immunization (EPI) in May 1974 with the objective to vaccinate children throughout the world. Ten years later, in 1984, the WHO established a standardized vaccination schedule for the original EPI vaccines: Bacillus Calmette-Guérin (BCG), diphtheria-tetanus-pertussis (DTP), oral polio, and measles. Increased knowledge of the immunologic factors of disease led to new vaccines being developed and added to the EPI’s list of recommended vaccines: Hepatitis B (HepB), yellow fever in countries endemic for the disease, and Haemophilus influenzae meningitis (Hib) conjugate vaccine in countries with high burden of disease.

In 1999, the Global Alliance for Vaccines and Immunization (GAVI) was created with the sole purpose of improving child health in the poorest countries by extending the reach of the EPI. The GAVI brought together a grand coalition, including the UN agencies and institutions (WHO, UNICEF, the World Bank), public health institutes, donor and implementing countries, the Bill and Melinda Gates Foundation and The Rockefeller Foundation, the vaccine industry, non-governmental organizations (NGOs) and many more. The creation of the GAVI has helped to renew interest and maintain the importance of immunizations in battling the world’s large burden of infectious diseases.

The current goals of the EPI are: to ensure full immunization of children under one year of age in every district, to globally eradicate poliomyelitis, to reduce maternal and neonatal tetanus to an incidence rate of less than one case per 1,000 births by 2005, to cut in half the number of measles-related deaths that occurred in 1999, and to extend all new vaccine and preventive health interventions to children in all districts in the world.

In addition, the GAVI has set up specific milestones to achieve the EPI goals: that by 2010 all countries have routine immunization coverage of 90% of their child population, that HepB be introduced in 80% of all countries by 2007 and that 50% of the poorest countries have Hib vaccine by 2005.

IMPLEMENTATION

In each of the United Nations’ member states, the individual national governments create and implement their own policies for vaccination programs following the guidelines set by the EPI. Setting up an immunization program is multifaceted and contains many complex components including a reliable cold chain system, transport for the delivery of the vaccines, maintenance of vaccine stocks, training and monitoring of health workers, outreach educational programs to inform the public, and a means of documenting and recording which child receives which vaccines.

Each distinct region has slightly varying ways of setting up and implementing their own immunization programs based on their existing level of health infrastructure. Some areas will have fixed sites for vaccination: healthcare facilities such as hospitals or health posts that include vaccination along with many other health care activities. But in areas where the number of structured health facilities is small, mobile vaccination teams consisting of staff members from a health facility can deliver vaccines straight to individual towns and villages. These ‘outreach’ services are often scheduled throughout the year. However, in especially under-developed countries where proper communication and infrastructure is absent, cancellation of the planned immunization visits leads to deterioration of the program. A better strategy in such countries is the ‘pulse immunization’ technique, where ‘pulses’ of vaccines are given to children in annual vaccination campaigns.

Additional strategies are needed if the area of the immunization program consists of poor urban communities because such areas tend to have low uptake of vaccination programs. Door-to-door canvassing, also referred to as channeling, is used to increase uptake in such hard to reach groups. Finally, periodic national level mass vaccination campaigns are being increasingly included in the immunization programs.

EVALUATION

In each country, immunization programs are monitored using two different methods: an administrative method and through community-based surveys. The administrative method involves using immunization data from public, private, and NGO clinics. Thus the accuracy of the administrative method is limited by the availability and accuracy of reports from these facilities. This method is easily performed in areas where the government services deliver the immunizations directly or where the government supplies the vaccines to the clinics. In countries without the infrastructure to do this, community based surveys are used to estimate immunization coverage.

Community-based surveys are applied using a modified cluster sampling survey method developed by the World Health Organization. Vaccine coverage is evaluated using a two-stage sampling approach in which 30 clusters and seven children within each cluster are selected. Health care workers with no or limited background in statistics and sampling are able to carry out data collection with minimal training. Such a survey implementation provides a way to get information from areas where there is no reliable data source. It is also used to validate reported vaccine coverage (for example, from administrative reports) and is expected to estimate vaccine coverage within 10 percent.

Surveys or questionnaires, though frequently considered inaccurate due to self-reporting, can provide more detailed information than administrative reports alone. If home based records are available, not only can vaccination status be determined but also dates of vaccination can be reviewed to determine if vaccinations were given at an ideal age and in appropriate intervals. Missed immunizations can be identified and further qualified. Importantly, other systems of vaccine delivery besides clinics used for administrative evaluation can be identified and included in analysis.

RESULTS

Prior to the initiation of the EPI, child vaccination coverage for tuberculosis, diphtheria, pertussis, tetanus, polio and measles was estimated to be fewer than 5 percent. Now, not only has coverage increased to 79 percent, but it has also been expanded to include other vaccinations such as for hepatitis B, Haemophilus influenzae type B, rubella, tetanus and yellow fever. The impact of increased vaccination is clear from the decreasing incidence of many diseases. For example, measles deaths decreased by 60% worldwide between 1999 and 2005, and polio, although missed the goal of eradication by 2005, has decreased significantly as there were less than 2000 cases in 2006.

PATH - INITIATION TO IMMUNIZATION

Collaborating locally to bring health within reach

PATH works in India’s highest-need, hardest-to-reach areas

PATH began working in India in 1978 to address some of the country’s crucial health problems. Over more than three decades, our program in the region has grown to become one of our largest. We work in some of the country’s highest-need and hardest-to-reach areas, collaborating with governments, communities, companies, researchers, and public health practitioners to find health solutions.

Preventing disease through vaccines and immunizations

PATH works in India to help develop new vaccines and vaccine technologies and strengthen immunization services  to reach even the most remote villages. We’re advancing new vaccines against malaria, meningitis, pneumococcal disease (the most common  cause of severe pneumonia), and rotavirus (the most common  cause of severe diarrhea) by collaborating with partners on vaccine development, formulation, manufacturing, and compliance with regulatory authorities.

We work closely with the Government of India to strengthen health systems to introduce new vaccines and improve access to immunization services. PATH is helping to increase immunization coverage for young children in the slums of Mumbai and the state of Madhya Pradesh. Through our partnership with the Indian government, we helped ensure that 78 million children nationwide received vaccine against Japanese encephalitis, a debilitating disease that in India strikes mainly poor, rural communities. We helped introduce hepatitis B vaccine in the routine immunization program. The vaccine is now available free of cost in most state immunization programs.

PATH also facilitates research in India on methods to protect vaccines from damage due to exposure to extreme temperatures during transport and storage. Because reuse of needles can increase the risk of spreading HIV, hepatitis B, and other infections, PATH has supported manufacturers to mass-produce single-use syringes to make them available and affordable.

Improving health for mothers and children

Every year, thousands of children in India die within a month of birth. Thousands more survive, but grow up weak or sickly. Often, these outcomes could be avoided with increased health education. Through PATH’s Sure Start project, we and our nearly 90 local partners are enhancing India’s health system while helping families understand simple steps they can take to help their babies thrive.

Despite advances, women in India continue to be threatened by two highly preventable causes of death: postpartum hemorrhage and cervical cancer. India’s maternal mortality rate is 407 per 100,000 live births; 30 percent of the deaths are due to excessive bleeding after childbirth. PATH is working to understand the factors that lead to the inappropriate use of oxytocin—a drug with the potential to dramatically decrease postpartum hemorrhage—and to determine how to use it safely. We’re also gathering information that will help India establish a comprehensive cervical cancer prevention plan.

Access to safe water and healthy food

Millions of poor families in India lack access to safe drinking water, a condition that poses a daily threat to their health. We conducted extensive testing with potential users to design a household water treatment and storage device for Indian families. Now, we’re collaborating with manufacturers and distributors to provide a product that has the potential to make safe drinking water available and affordable.

To alleviate the debilitating effects of micronutrient malnutrition, PATH developed a pasta-like “grain” called Ultra Rice® that is manufactured from rice flour and essential vitamins and minerals. When blended with milled rice, typically at a 1:100 ratio, the resulting fortified rice is nearly identical to traditional rice in smell, taste, and texture. In India, we’ve established the safety and efficacy of the Ultra Rice® technology and are now working with partners of the Government’s Mid-Day Meal program to serve fortified rice to 185,000 schoolchildren daily.

Controlling tuberculosis

India has the highest burden of tuberculosis (TB) in the world. With 1.8 million cases occurring annually and 333,000 deaths from TB, India accounts for one-fifth of the world’s new TB cases and two-thirds of the cases in Southeast Asia. More than 70 percent of cases occur in the economically productive 15– to 54-year-old age group. Their deaths take a terrible toll on families and economies. PATH supports the government nationally and across 26 states by strengthening communication, laboratories, infection control, and surveillance of multidrug-resistant TB.