Enhancing immunization during second year of life by reducing missed opportunities for vaccinations in 46 countries Celina M. Hanson a,⇑ , Imran Mirza a , Richard Kumapley a , Ikechukwu Ogbuanu b , Robert Kezaala a , Robin Nandy a a United Nations Children’s Fund (UNICEF), 3 UN Plaza, New York, NY 10017, USA b World Health Organization (WHO), Avenue Appia 20, Geneva 1202, Switzerland article info Article history: Received 19 February 2018 Received in revised form 22 April 2018 Accepted 23 April 2018 Available online xxxx Keywords: Vaccination Missed opportunities Second year of life Immunization Service delivery abstract Background: Delivering vaccination services during the second year of life (2YL) 1 provides countries with an opportunity to achieve greater coverage, to provide booster doses and vaccines missed during the first year of life, as well as contribute towards disease control and elimination goals. Methods: Using data from demographic health surveys (DHSs) conducted during 2010 to 2016, this paper explores the proportion of missed opportunities for vaccinations generally provided during routine immunization among children in their 2YL. Results: DHS data in 46 countries surveyed 478,737 children, from which 169,259 children were 12–23 months old and had vaccination/health cards viewed by surveyors. From this group, 69,489 children aged 12–23 months had contact with health services in their 2YL. Three scenarios for a missed opportunity for vaccinations were analysed: (1) a child received one vaccine in the immunization schedule and was eli- gible for another vaccine, but did not receive any further vaccination, (2) a child received a vitamin A sup- plementation (VAS) and was due for a vaccine, but did not receive vaccines that were due, and (3) a child was taken to a health facility for a sick visit and was due (and eligible) for a vaccine, but did not receive the vaccine. A total of 16,409 (24%) children had one or more missed opportunities for vaccinations. Conclusion: This analysis highlights the magnitude of the problem of missed opportunities in the 2YL. The global community needs to provide better streamlined guidance, policies and strategies to promote vac- cination screenings at well-child and sick child visits in the 2YL. Where they do not exist, well-child visits in the 2YL should be established and strengthened. Ó 2018 Elsevier Ltd. All rights reserved. 1. Introduction Although estimated global immunization coverage has increased substantially since the start of the Expanded Programme on Immunization (EPI) in 1974, coverage of the third dose of diphtheria-tetanus pertussis vaccine (DTP3) has remained stag- nant at around 85% since 2010 [1] and vaccine-preventable dis- eases remain a major cause of morbidity and mortality worldwide. In 2016, an estimated 6.6 million infants who did receive their first dose of DTP-containing vaccine did not complete the three-dose DTP series [2]. The Global Vaccine Action Plan (GVAP) provides a framework for making vaccines available to all individuals globally and calls on all countries to reach at least 90% national coverage and at least 80% district-level coverage for all vaccines in the country’s national immunization schedule by 2020 [3]. One approach to achieving these goals is to provide vaccination to all eligible persons at every opportunity, including at preventive and curative health service visits. Recommendations for this approach were established by the World Health Organization (WHO) EPI Global Advisory Group in 1983 [4]. More effort is required to increase vaccination coverage. According to recent analyses of demographic health surveys (DHS), ten percent of all children aged below five years in 96 coun- tries did not receive any vaccines and 46% were only partially vac- cinated [5]. In addition, a 2014 review conducted in low- and middle-income countries concluded that missed opportunities for vaccination (MOVs) occurred in 32–46% of public health service encounters [6]. Timely vaccination is recommended, but weak immunization and public health systems play a key role in children not receiving vaccines or being incompletely vaccinated. Key factors can include https://doi.org/10.1016/j.vaccine.2018.04.070 0264-410X/Ó 2018 Elsevier Ltd. All rights reserved. ⇑ Corresponding author. E-mail address: chanson@unicef.org (C.M. Hanson). 1 Abbreviations: 2YL, denotes Second Year of Life or 2nd Year of Life. Vaccine xxx (2018) xxx–xxx Contents lists available at ScienceDirect Vaccine journal homepage: www.elsevier.com/locate/vaccine Please cite this article in press as: Hanson CM et al. Enhancing immunization during second year of life by reducing missed opportunities for vaccinations in 46 countries. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2018.04.070