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View the document Session: Improving immunization coverage - The community's role

Unit 6: Immunization

SESSION: Improving Immunization Coverage - The Community's Role

Session: Improving immunization coverage - The community's role

Measles, whooping cough (pertussis) and tuberculosis are diseases that can have an extremely negative effect on the nutrition status and the survival of young children. These illnesses, together with diphtheria, tetanus and polio, are preventable through immunization. Most countries have started national programs that aim to achieve immunization of all children under five years old against these diseases. Because it is difficult to obtain, transport and store the vaccines, immunization programs are usually managed by regional or district health officers. Communities can make sure that all of their young children are immunized by:

- Contacting the national immunization program or the nearest health office and requesting that vaccinators visit their communities regularly.

- Promoting immunization and organizing immunization sessions in the community.

- Identifying and referring all children with incomplete immunization coverage to the vaccination team.


Trainees discuss the national guidelines for immunization of women and young children and learn to identify children with incomplete immunization coverage. The steps a community might take to organize immunization sessions are detailed.

Time: 2 hours


- Handouts -

- Immunization Overview

- Understanding the Target Diseases

- Sample Immunization Schedules

- Immunization Problems: Missed Dates, Reactions and Sick Children

- Exercise: "Identifying Children Who Need Immunization"

- Educational material 5 available to trainees for promotion of immunization


1. Discuss the importance of immunization programs by going over the handouts "Immunization Overview" and Understanding the Six Target Diseases".

2. Using the following growth charts and the wall-sized growth chart, show the effects that measles, tuberculosis and whooping cough (pertussis) can have on the growth and survival of young children. Point out that these diseases can cause malnutrition in healthy children. In malnourished children, they often cause death.


Whooping Cough


3. Review the immunization schedule handouts so trainees become familiar with the vaccines, number of doses and recommended ages and intervals for vaccination. Note that there are 3 schedules, the WHO standard recommended schedule, and illustrative examples for the simplified schedule and the single day campaigns.

4. Discuss some of the immunization problems noted in the handout that may occur such as missed dates, reactions and sick children. Explore ways in which the community can work with families and children to overcome these problems, and also other problems they may encounter related to traditional practices and cultural beliefs.

5. Go through the exercise on "Identifying Children Who Need Immunization" in order to demonstrate what is necessary to achieve full vaccination coverage.

- Use the WHO recommended vaccination schedule handout to review what is full coverage for each disease.

- Each trainee should complete the exercise form (using the WHO standard schedule) and note which children are not fully vaccinated. It should be stressed that those children who have not received all 3 doses for both DPT and polio are not fully covered. Also, we cannot simply total the number of DPT and polio vaccines given and assume that this total equals the number of children protected since 3 doses per child are required.

6. Discuss and list on the flipchart the steps trainees would take to improve the immunization coverage in this neighborhood.

7. Draw a diagram like the one below to summarize the steps a community might take to promote and organize immunization activities.

Diagram of activities

8. Explore ways in which the trainees might be able to mobilize the community to participate in immunization programs. Trainees who have organized community immunization activities may wish to tell the group about their successes and their problems. Problems raised should be discussed by asking trainees to suggest possible causes and solutions for each problem.

9. Help trainees identify whom to contact in their region to request immunization services.

10. Show educational materials available for community immunization promotion and explain how trainees can obtain them.

11. Summarize the session

- Several serious diseases that cause malnutrition and death can be prevented by immunization. These include measles, tuberculosis, diphtheria, pertussis, tetanus and polio.

- By identifying women and children who need immunization, and by coordinating with national and regional health officials, communities can insure protection from these deadly diseases.



Six preventable childhood diseases for which vaccines are widely available are measles, pertussis (whooping cough), tetanus, polio, diphtheria and tuberculosis. Of these, measles is the most clearly related to diarrhea. Diarrhea often follows an episode of measles, and the combination of the two illnesses can be fatal. It is estimated that up to 26 percent of diarrhea-associated mortality could be prevented by measles vaccination. (1) Pneumonia, malnutrition and shigella dysentery are complications associated with measles. Preventing measles could also reduce the incidence of malnutrition and vitamin A deficiency, both of which are associated with serious attacks of diarrhea.

(1) R.G. Feachem and M.A. Koblinsky: Interventions for the control of diarrhoeal diseases among young children: measles immunization. Bulletin WHO 61, 641-652, 1983.

What is immunization?

Immunization is the giving of a vaccine or vaccines to stimulate the body to create immunity against specific diseases. Immunity is the body's ability to protect itself against the bacteria and viruses which cause disease.

Why immunize?

Every year in developing countries 110 million episodes of illness occur which could be prevented by immunization. As a result 3.5 million children die. Children with these illnesses are also more likely to develop other infections, such as diarrhea, as their resistance and ability to fight off infection is reduced. Widespread use of vaccines in the developed world is a major factor in the reduced mortality and morbidity from these six diseases and associated illnesses.. Immunization is a more effective way of using scarce resources than treating diseases after they occur.

The six major childhood immunizations


- Measles vaccine is made from live measles virus which has been weakened (or attenuated) and is given subcutaneously in one dose. The infection provides long lasting protection against measles. Those vaccinated may feel unwell with a mild fever, and/or rash five to ten days after vaccination.

Diphtheria, pertussis, tetanus

- DPT vaccine combines diphtheria, pertussis (whooping cough), and tetanus immunizations in one injection. The injection is given intramuscularly in three doses four weeks or more apart and protects for at least ten years against the three diseases. Common side effects to the injection include fever and redness and swelling at the injection site.


- The oral polio vaccine contains the weakened viruses of the three types that cause polio. It usually provides permanent protection against this crippling disease, and is given in three doses 4 weeks or more apart (usually at the same time as DPT In countries where polio remains endemic, if possible, a child should receive an additional polio vaccination at birth.


- BCG vaccine its given intradermally (within the skin layer, raising a blister) and guards against tuberculosis (TB). Studies concerning efficacy of the BCG vaccine have produced conflicting reports. Most people agree that it gives good protection against the lethal forms of childhood TB. An ulcer forms at the injection site and heals without treatment, forming a scar.

Reprinted from Dialogue on Diarrhoea, "Health Basics: Immunization", Issue 30, September 1987, Appropriate Health Resources and Technologies Action Group, Ltd., London.



(1) Measles. Measles is a highly contagious disease which 90 percent of the unprotected under-five population contract in some countries. A relatively mild disease in developed countries, measles is a major cause of childhood mortality in many developing countries, particularly in Africa and Central America. Poor nutritional status seems to be the main factor leading to the most severe consequences of measles. The common practice of withholding food during a child's illness exacerbates the condition. Death is caused by pneumonia, diarrhea, or in a small number of cases, encephalitis, in association with the disease. Maternal antibodies transferred through the placenta protect the infant during the first months of life. If measles vaccine is given to the infant before nine months of age, these antibodies may prevent the vaccine from producing immunity in the child. But if the child is vaccinated too late, the period of greatest danger to the child will be past. The seasonality of measles incidence should also be considered in deciding age guidelines.

(2) Pertussis. Pertussis (whooping cough) is second to measles as a cause of morbidity and mortality among vaccine-preventable diseases in some developing countries. The World Health Organization estimates that up to 80 percent: of unimmunized children will contract it. Pertussis, an acute bacterial infection affecting the respiratory tract, is very contagious in the first week or two of infection. The spasmodic coughing or "whooping" that characterizes the disease is readily recognized and lasts one to two months. Pertussis is most severe in children under five months of age and may lead to death through pneumonia or other conditions. In very young children, there is no characteristic whoop, so the disease may be difficult to recognize. Immunity requires three vaccinations which may begin as early as six weeks of age.

(3) Tetanus. Caused by a toxin of a bacterium which enters the body through broken skin, this major killer of infants in developing countries is often caused by infection from the cut umbilical cord. Pregnant women who receive two tetanus toxoid immunizations pass immunity which protects the newborn during the first months of life. Tetanus bacteria reside in soil so, unlike smallpox, there is no hope of eliminating the reservoir of harmful organisms. Instead, protection comes only through immunization against the disease or through improved hygiene.

(4) Poliomyelitis. Polio is a vital disease spread by contact with objects, food, or water contaminated with excrete. Although polio infection is universal, most persons experience no symptoms. In a small minority of cases, polio leads to varying degrees of paralysis and, sometimes, death. The older the child at age of infection, the more likely the infection will lead to severe consequences. The use of polio vaccines in the last 20 years in developed countries has markedly reduced the incidence of polio; however, its relative infrequency has led to laxity and occasional outbreaks among the unimmunized. In developing countries, the incidence of paralytic polio appears to have been seriously under-estimated. Good evidence for the paralytic form of polio is lameness with no loss of the sense of touch in the affected limb.

(5) Tuberculosis (TB). TB is a bacterial disease spread by coughing and the sputum of infected persons. The disease takes many forms in children, infecting the bones, lungs, or brain. Often, it may not be recognized as the same disease that affects adults. TB is particularly common where many persons share the same crowded living quarters. In some cities in developing countries, one percent of the adults nay be in the active infective stage of the disease. Improved housing, clothing, diet, early detection, and uninterrupted treatment-all difficult to achieve in many developing countries- are al] necessary to effectively control TB. Even though BCG's efficacy under certain conditions has been questioned, it remains an important means of protecting many children in developing countries.

(6) Diphtheria. A major child killer of the past in temperate countries, the mortality and morbidity of diphtheria are the least well documented of the six diseases in developing countries today. Although typically manifested as an acute infection of the throat, diphtheria can affect the heart or brain of infants and young children. Vaccination against diphtheria over the past 50 years has eliminated the disease in many developed countries. Partial immunity acquired through skin infections with C. diphtheria in cuts and abrasions may protect many children in developing countries from the severe infection.

Of the six diseases reviewed here, measles and paralytic polio are the most likely to be eliminated in humans (although not eradicated from the environment) through a continuous and comprehensive immunization program. TB and tetanus are greatly influenced by general living conditions and sanitation, and will decrease as standards of housing and hygiene improve The overall incidence of measles and pertussis is not greatly affected by living standards, but cases are much less severe and occur later when children are well nourished. Diphtheria and polio,, by contrast, may actually increase as standards of living improve and children do not gain natural active immunity.

Reprinted from Immunizations: Information for Action Issue Paper; World Federation of Public Health Associations, May 1984.




Age at First

Number of

Minimum Interval Between Doses


BCG (intra-dermal Injection)




BCG given at the earliest possible age protects against the possibility of infection from other family members
BCG scar is often used as an indicator of previous BCG immunization

DPT (Intra-muscular injection)

6 weeks


1 month

An early start with OFT reduces the chances of severe pertussis. Followed by four week intervals for effective protection reduces the time a child is exposed without protection particularly to pertussis

Polio (Oral)



1 month

The extent of protection against polio Is increased the earlier the OPV is given

Measles (Sub- cutaneous. injection)

9 months



At least 60 per cent of measles in the third world can be prevented by immunization at this age


Women of child-bearing age

At least 2 doses before or during early pregnancy, should not be given later than 2 weeks before delivery

1 months

-for pregnant women with no previous tetanus immunization - 2 doses during pregnancy
- for pregnant women with 3 previous tetanus immunizations during childhood - 2 boosters during pregnancy required
- After 5 doses, all children born are protected from maternal tetanus

*BCG: Bacillus Calmette Guerin (against TB)

*OPV: Oral Poliovirus Vaccine (dose at birth is in addition to the standard schedule of 3 doses)

*DPT: Diphtherial/ Petussis/ Tetanus Toxoid


Simplified schedule for remote population (two contacts as used in parts of West Africa)





All children
3-8 months old

IPV in two doses is protective against paralytic polio


All children
9-14 months old

In remote areas the average age of contracting measles is delayed to the second and third years of life and later vaccination is still effective


IPV: Inactive Poliovirus Vaccine

DPT-IPV may be obtained in a single preparation

EPI also recommends that OPV be added to this schedule


Semi-annual single day "pulse" campaigns (as used in Brazil)



Number of Doses



All children
0-59 months old

Up to 10 doses

After regular vaccination with OPV vaccine. the virus replaces the naturally occurring disease- causing virus in the environment


All children
9-23 months old

Up to 2 doses

Giving a second dose of measles vaccine increases effective coverage


All children
2-11 months old

2 doses

Third DPT through regular primary health care services in clinics; 2 doses of DPT are partially effective(50-60%) against pertussis


Immunization Schedule

Infants and children

All children should be immunized against the preventable childhood diseases. The immunization schedule describes the number of times that a child needs to be given vaccinations and how far apart each visit should be. Following the ideal schedule, each child should be fully immunized by the age of nine months, or soon after, because infants are at greater risk from these diseases. Many countries try to immunize all children under five years of age who may be at risk.


Neonatal tetanus is prevented for several years by immunizing women of child-bearing age with at least two doses of tetanus toxoid. After five doses of tetanus toxoid all children born subsequently are protected from neonatal tetanus. A woman who received three doses of DPT as a child will greatly increase her infants' protection by two boosters (ideally before or during early pregnancy) when she is ready to bear children. (Hygienic cord treatment can also prevent neonatal tetanus but is not as effective as complete immunization of the mother.)

(Above reprinted from Dialogue on Diarrhoea, "Health Basics: Immunization," Issue 30, September, 1987)

The following handouts present 3 immunization schedules. The WHO recommended schedule provides the optimum schedule in which a child will be fully immunized by 9 months. However, recognizing that numerous children in many developing countries have not been immunized according to this schedule, children may begin to receive vaccinations at an older age. In addition, other program approaches have been implemented in efforts to address this deficiency in providing widespread vaccination coverage to children. Two other illustrative approaches, the simplified schedule and the pulse campaign are also presented. The simplified schedule focuses on vaccinating younger children under 14 months through 2 contacts. These 2 contacts can be spaced according to the country situation. This approach has been restricted primarily to Francophone Africa to date. The pulse campaign also focuses on children up to 2 years for measles and DPT and up to 5 years for polio. The pulse campaign, also often referred to as a mass campaign, is carried out in an effort to catch up the backlog of children that May not have been previously vaccinated and may also fall outside the normal health care network responsible for vaccination programs. However, most country immunization programs continue to follow the WHO recommended schedule.


Immunization Problems: Missed Dates, Reactions and Sick Children

If it is not possible to bring a child for immunization on the right day-, the immunization must be given as soon as possible afterwards. Once begun, a series of immunizations. must be completed to be effective. Even if the time between immunizations is longer than recommended, the next dose in the polio and DPT series is given; there is no need to start from the beginning again. Only a completed series of immunizations adequately protects a child. In remote areas, and places where for other reasons it is not possible to do this, simplified schedules and mass immunization days have been used.

Vaccine schedules have to suit the circumstances in particular countries. Ideally, most developing countries should follow the WHO recommended schedule of five contacts but this requires an effective health infrastructure to which all people have access. Mass campaigns, with immunization days, can successfully increase awareness about immunization and vaccinate large numbers of children. However, only when health systems are developed to ensure regular vaccination of all newly born children every year, will full coverage be achieved.

Reaction to Immunization

After immunization some children develop mild reactions, such as fever, or a swollen area around the injection site. This is quite normal with some vaccines and may be part of the body's response to developing protection. Parents should be told that this is likely to happen so that they do not worry about it and it does not prevent them:

- from bringing the child back for further immunization doses; or

- from bringing their other children to the clinic for immunization.

Can a sick child be immunized?

Mothers sometimes do not bring a sick child for immunization and if they do, health workers frequently do not immunize them. Mothers and health workers need to know that all EPI immunizations are safe and effective even if a child is ill with fever, diarrhea, vomiting, or respiratory infection. No chance should be missed to immunize a child. This is a recommendation of the EPI.

The benefits of immunization far outweigh the risk, especially in malnourished children. Only- in very few exceptional cases is it not advisable to immunize. For example, a child who has had a severe reaction to DPT (fits, extreme crying) should not be given pertussis immunization, but should get diphtheria-tetanus vaccine.

Reprinted from Dialogue on Diarrhoea, "Health Basics: Immunization," Issue 30, September 1987.


1. You have just completed an immunization survey In your neighborhood. By interviewing mothers and reviewing immunization cards, you collected the following information:

Maria (13 months)

- no vaccines

Jane (18 months)

- BCG, measles

John (2 years)

- BCG, Polio I

Ruth (4 years)

- BCG, measles

Henry (3 years)

- BCG,

Caroline (7 months)

- no vaccines

Edward (6 months)

- no vaccines

Susan (2 1/2 years)

- BCG,

Richard (4 months)

- no vaccines

Peggy (4 1/2 years)

- Measles, DPT I & II, Polio I & II

Tom (3 years)

- no vaccines

Mary (1 year)

- no vaccines

Ellen (4 1/2 years)

- Measles, BCG,

Louisa (3 years)

- no vaccines

2. Transfer this information to the chart below. Complete one column on the chart for each child, by writing the child's name at the top and putting on X In the column next to the vaccines each child has taken.

Children 0-5 Years NAME:




1 dose




1. dose




1. dose


2. dose


3. dose




1. dose


2. dose


3. dose


3. Answer the questions below about the immunization status of children in your neighborhood.

- How many children were included in your survey?

- How many children have not had the following immunizations?



% of Total Children





DPT (3 doses)


Polio (3 doses)


What will you do to achieve your goal of completed immunizations for all children in the neighborhood?


World Federation of Public Health Associations. Immunizations: Information for Action Issue Paper. May 1984.

American Public Health Association. Immunization. 1982.

Appropriate Health Resources & Technologies Action Group Ltd. Dialogue on Diarrhoea, "Health Basics: Immunization," Issue 30, London. September 1987.

For further information:

Werner, David. Where There Is No Doctor: A Village Health Care Handbook. The Hesperian Foundation, P.O. Box 1692, Palo Alto, CA, 94302.

Werner, David and Bill Bower. Helping Health Workers Learn, 1982. The Hesperian Foundation, Palo Alto, CA