From reaching every district to reaching every community: analysis and response to the challenge of equity in immunization in Cambodia.

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.

Ensuring injection safety during measles immunization campaigns: more than auto-disable syringes and safety boxes.

Measles immunization campaigns are effective elements of a comprehensive strategy for preventing measles cases and deaths. However, if immunizations are not properly administered or if immunization waste products are not safely managed, there is the potential to transmit bloodborne pathogens (e.g., human immunodeficiency virus and hepatitis B and hepatitis C). A safe injection can be defined as one that results in no harm to the recipient, the vaccinator, and the surrounding community. Proper equipment, such as the exclusive use of auto-disable syringes and safety boxes, is necessary, but these alone are not sufficient to ensure injection safety in immunization campaigns. Equally important are careful planning and managerial activities that include policy and strategy development, financing, budgeting, logistics, training, supervision, and monitoring. The key elements that must be in place to ensure injection safety in measles immunization campaigns are outlined.