Comment 1500 www.thelancet.com Vol 373 May 2, 2009 A disadvantage of early vaccination in infancy can be reduced immunogenicity because of acquired immune responses that are less mature, and interference from maternal antibodies. However, newer vaccines supported for potential introduction into some developing countries pose safety as well as efficacy questions about timing. More than 30% of children in most countries surveyed by Clark and Sanderson were vaccinated later than the current recommended safety cutoff for the first dose of rotavirus vaccine, which is 12 weeks. An increased risk of intussusception was seen in US infants who received their first dose of Rotashield after 12 weeks of age. 11 Information from postlicensure safety surveillance in developed countries for the newer rotavirus vaccines will hopefully enable the 12 week cutoff to be removed but, until this time, many children could be prevented from receiving a rota- virus vaccine. Additionally, onset of rotaviral disease in developing countries is earlier than that in developed countries, which underlines the importance of early vaccination. 12 There is some cause for optimism. Countries as diverse as Rwanda, Egypt, and Peru provide high coverage with timely administration. Many countries use opportunistic immunisation to minimise missed opportunities. 5 Poten- tially generalisable lessons can be learnt from these successes. *Jim P Buttery, Stephen M Graham A global fund for the health MDGs? The world is off track to achieve the health-related targets of the Millennium Development Goals (MDGs) by 2015. 1 Maternal mortality has stagnated for two decades, 2 child mortality is not declining fast enough, 3 HIV/AIDS still infects people faster than the pace of antiretroviral treatment roll-out, 4 and inequalities are widening within and across countries. 5 Addressing these crises will require increased funding and more efficient spending. The next Board meetings of the Global Fund to Fight AIDS, Tuberculosis and Malaria and the GAVI Alliance, scheduled for May and June, respectively, present an opportunity to tackle these issues. There is widespread recognition of the need for bold action to streamline the global aid architecture for health. Last year WHO launched an effort to “Maximise positive synergies between global health initiatives and health systems”, 6 whose conclusions will be submitted to the G8 in late June. A Taskforce on Innovative International Financing for Health Systems was established in September, 2008, to explore new strategies to mobilise and channel resources for health systems. 7 The executive directors of the GAVI Alliance and the Global Fund recently wrote to the Taskforce co-chairs that “It is time to take a comprehensive approach with the necessary support from key donors to refocus on all of the health-related MDGs”. 8 An interim report from one of the Taskforce working groups suggests considering “the Global Fund and GAVI as a conduit for additional resources for health Murdoch Children’s Research Institute and Centre for International Child Heath, Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Parkville 3052, VIC, Australia (JPB, SG); and Department of Paediatrics, Monash University, Clayton, VIC, Australia (JPB) jim.buttery@mcri.edu.au We declare that we have no conflict of interest. 1 Lim SS, Stein DB, Charrow A, Murray CJL. Tracking progress towards universal childhood immunisation and the impact of global initiatives: a systematic analysis of three-dose diphtheria, tetanus, and pertussis immunisation coverage. Lancet 2008; 372: 2031–46. 2 Semba RD, de Pee S, Berger SG, Martini E, Ricks MO, Bloem MW. Malnutrition and infectious disease morbidity among children missed by the childhood immunization program in Indonesia. Southeast Asian J Trop Med Public Health 2007; 38: 120–29. 3 Bates AS, Fitzgerald JF, Dittus RS, Wolinsky FD. Risk factors for underimmunization in poor urban infants. JAMA 1994; 272: 1105–10. 4 Jani JV, De Schacht C, Jani IV, Bjune G. Risk factors for incomplete vaccination and missed opportunity for immunization in rural Mozambique. BMC Public Health 2008; 8: 161. 5 Clark A, Sanderson C. Timing of children’s vaccinations in 45 low-income and middle-income countries: an analysis of survey data. Lancet 2009; published online March 20. DOI:10.1016/S0140-6736(09)60317-2. 6 Ruff TA, Gertig DM, Otto BF, et al. Lombok Hepatitis B Model Immunization Project: toward universal infant hepatitis B immunization in Indonesia. J Infect Dis 1995; 171: 290–96. 7 Bisgard KM, Rhodes P, Connelly BL, et al, on behalf of the Centers for Disease Control and Prevention. Pertussis vaccine effectiveness among children 6 to 59 months of age in the United States, 1998–2001. Pediatrics 2005; 116: e285–94. 8 Daly AD, Nxumalo MP, Biellik RJ. Missed opportunities for vaccination in health facilities in Swaziland. S Afr Med J 2003; 93: 606–10. 9 Szilagyi PG, Rodewald LE. Missed opportunities for immunizations: a review of the evidence. J Public Health Manag Pract 1996; 2: 18–25. 10 Murakami H, Van Cuong NV, Tuan HV, Tsukamoto K, Hien DS. Epidemiological impact of a nationwide measles immunization campaign in Viet Nam: a critical review. Bull World Health Organ 2008; 86: 948–55. 11 Simonsen L, Viboud C, Elixhauser A, Taylor RJ, Kapikian AZ. More on RotaShield and intussusception: the role of age at the time of vaccination. J Infect Dis 2005; 192 (suppl 1): S36–43. 12 Cunliffe NA, Kilgore PE, Bresee JS, et al. Epidemiology of rotavirus diarrhoea in Africa: a review to assess the need for rotavirus immunization. Bull World Health Organ 1998; 76: 525–37.