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Despite achieving and sustaining global measles vaccination coverage of about 80% over the past decade, worldwide measles remains the fifth leading cause of mortality among children aged <5 years. In May 2002, the United Nations Special Session on Children endorsed the goal of reducing measles deaths by half by 2005. Countries and World Health Organization (WHO) regions that adopted aggressive measles control or elimination strategies have shown excellent results. In 2001, countries in the Americas reported an all time low of 537 confirmed measles cases. Substantial progress in measles control has also been achieved in the WHO Western Pacific Region, in seven southern African countries, and in selected countries in WHO European, Eastern Mediterranean, and Southeast Asian regions. The ongoing measles disease burden and availability of safe and effective measles mortality reduction strategies make a compelling case to complete the unfinished agenda of measles immunization.

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Background An international review of the Cambodian Expanded Programme on Immunization (EPI) in 2010 and other data show that despite immunization coverage increases and vaccine preventable diseases incidence reductions, inequities in access to immunization services exist. Utilizing immunization and health systems literature, analysis of global health databases and the EPI review findings, this paper examines the characteristics of immunization access and outcome inequities, and describes proposed longer-term strategic and operational responses to these problems.Findings The national programme has evolved from earlier central and provincial level planning to strengthening routine immunization coverage through the District level ‘Reaching Every District Strategy’. However, despite remarkable improvements, the review found over 20% of children surveyed were not fully immunized, primarily from communities where inequities of both access and impact persist. These inequities relate mainly to socio-economic exposures including wealth and education level, population mobility and ethnicity. To address these problems, a shift in strategic and operational response is proposed that will include (a) a re-focus of planning on facility level to detect disadvantaged communities, (b) establishment of monitoring systems to provide detailed information on community access and utilization, (c) development of communication strategies and health networks that enable providers to adjust service delivery according to the needs of vulnerable populations, and (d) securing financial, management and political commitment for ‘reaching every community’.Conclusions For Cambodia to achieve its immunization equity objectives and disease reduction goals, a shift of emphasis to health centre and community is needed. This approach will maximize the benefits of new vaccine introduction in the coming ‘Decade of Vaccines’, plus potentially extend the reach of other life-saving maternal and child health interventions to the socially disadvantaged, both in Cambodia and in other countries with a similar level of development.

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Infant immunization coverage in the Western Pacific Region of the World Health Organization was reviewed to evaluate the impact of polio eradication activities on routine immunization services. The trend in bacille Calmette-Guérin (one dose; BCG), diphtheria-tetanus toxoids-pertussis (three doses; DTP3), and measles (one dose) vaccination rates was analyzed from the beginning of eradication activities in 1990 to 1994 in the five polio-endemic countries that conducted supplementary oral polio vaccine immunization. In China and the Philippines, coverage for each antigen remained at or above 90% and 85%, respectively, while in Vietnam, coverage for all three antigens rose from 85% to 95%. BCG, DTP3, and measles vaccine coverage more than doubled in the People's Democratic Republic of Lao and increased by >30% in the Kingdom of Cambodia during the same period.

Within the overall framework set out in the Global Immunization Vision and Strategy (GIVS) for the period 2006-2015, over 70 countries had developed comprehensive Multi-Year Plans (cMYPs) by 2008, outlining their plans for implementing the GIVS strategies and for attaining the GIVS Goals at the midpoint in 2010 or earlier. These goals are to: (1) reach ≥90% and ≥80% vaccination coverage at national and district level, respectively; and (2) reduce measles-related mortality by 90% compared with the 2000 level. Fifty cMYPs were analysed along the four strategic areas of the GIVS: (1) protecting more people in a changing world; (2) introducing new vaccines and technologies; (3) integrating immunization, other health interventions and surveillance in the health system context; and (4) immunizing in the context of global interdependence. By 2010, all 50 countries planned to have introduced hepatitis B (HepB) vaccine, 48 the Haemophilus influenzae type B (Hib) vaccine and only a few countries had firm plans to introduce pneumococcal or rotavirus vaccines. Countries seem to be inadequately prepared in terms of cold-chain requirements to deal with the expected increases in storage that will be required for vaccines, and in making provisions to establish a corresponding surveillance system for planned new vaccine introductions. Immunization contacts are used to deliver other health interventions, especially in the countries in the World Health Organization (WHO) Africa Region. The cost for the planned immunization activities will double to U$27 per infant, of which U$5 per infant is the expected shortfall. Global Alliance for Vaccines and Immunization (GAVI) funding is becoming the largest contributor to immunization programmes.

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