Click here to go the the WHO Global Immunization News (GIN) site.
This Newsletter is in PDF file format. To view this PDF file you will need the Adobe Acrobat Reader, available free at: www.adobe.com
PAHO Articles published to GIN
As part of the activities conducted during the 11th Vaccination Week in the Americas & 2nd World Immunization Week; Dr. Jorge Villavicencio, Ministry of Health of Guatemala, swore in the members of Guatemala’s national Immunization Advisory Committee (CONAPI, in Spanish). The role and responsibilities of CONAPI´s members are regulated by Ministerial Agreement (MA) number 464-2013.
From 20-24 May 2013, a Haitian team from the Expanded Programme on Immunization (EPI) joined the EPI team of neighboring Dominican Republic (DR) in Santo Domingo for the DR to share its experiences in introducing the rota-virus vaccine into their National Immunization Programme last year.
Location: Antigua, Guatemala
Dates: 25 February – 1 March 2013
Purpose: 1) To exchange experiences and lessons learned in the implementation of pilot efforts in Central America to evaluate influenza vaccine effectiveness 2) To learn about the experiences of I-MOVE (a European Network to measure the effectiveness of influenza vaccines) and 3) To gauge country interest in conforming a similar network in the Americas.
Participants: Technical staff representing the influenza surveillance and immunization programmes of the Ministries of Health of Argentina, Brazil, Colombia, Costa Rica, Cuba, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Paraguay, and Uruguay, the European I-MOVE network, the Centers for Disease Control and Prevention (CDC), the Training Program in Epidemiology and Public Health Interventions Network (TEPHINET), and PAHO.
Location: Santo Domingo, Dominican Republic
Dates: 24-26 January 2013
Participants: Vice-Minister of Health of Dominican Republic, Dr. Rafael Schiffino, as well as the EPI Manager, Dr. Zacarias Garib and cooperation agencies such as PAHO and UNICEF, EPI managers from the 38 provinces.
Purpose: To evaluate the EPI performance during 2012, at the national, regional and provincial level, in order to identify challenges that should be overcome during 2013. This exercise will improve the planning process of the EPI programs, by effectively prioritizing the allocation of resources to those activities that will reduce the challenges confronted during 2012.
Location:Sao Paulo, Brazil
Dates: 5-6 March 2013
Participants:Pan American Organization, Sabin Vaccine Institute, the International Vaccine Access Center at Johns Hopkins University, Center for Diseases Control and Prevention, and epidemiological surveillance direc-tors from 26 countries.
Purpose: To assess the pneumococcal epidemiological profile in the region, and discuss the challenges and op-portunities of surveillance and vaccination in older children and adult populations.
Location: Panama City, Panama
Dates: 19–21 February 2013
Participants: Experts from Argentina, Brazil, Colombia, Cuba, El Salvador, Mexico, Panama and US CDC; country/regional PAHO staff
Purpose: To convene the regional experts steering the project
The Haitian Government presented on 27 February 2013, the National Plan for the Elimination of Cholera in Haiti, 2013–2022. This plan outlines a comprehensive set of actions for cholera prevention and control, including the deployment of oral cholera vaccine (OCV). During the period 2013–2015, OCV campaigns are planned for densely populated agglomerations in metropolitan areas and remote rural communities that are difficult to access. Epidemiological analysis defines the areas to target. On the medium and long terms (2016–2022), OCV may continue to be deployed leveraging its distribution to strengthen the provision of other measures of cholera control and prevention (such as reinforcing case management, surveillance, hygiene and health promotion, and services for water and sanitation) and national immunization services.
Pertussis is endemic in the Region of the Americas and many countries report outbreaks or epidemics every four to six years. In an effort to better understand this disease, PAHO/WHO’s Technical Advisory Group (TAG) on Immunizations has established a Working Group to develop a tool to aide in the investigation and reporting of pertussis outbreaks, in order to collect information that is comparable between outbreaks and across countries. The first meeting of this Working Group was held from 4-5 March 2013 and a second meeting will take place from 6-7 May 2013. During the first meeting, a format for investigating and reporting pertussis outbreaks was de-veloped, which is now being disseminated among epidemiologists in the Region in order to solicit their comments. During the upcoming May meeting, the Working Group will analyze feedback given regarding the above document and they will also examine the pertussis outbreak reports that have occurred over the last three years. These reports will allow for the analysis of the magnitude of the outbreaks, the epidemiology of the cases, the criteria used to confirm and discard cases, case definitions, and the laboratory methods employed.
The Pan American Health Organization’s (PAHO) ProVac Initiative is providing technical support to the National Immunization Program (NIP) in Honduras to develop a costing study, while piloting the ProVac Costing Tool. This study aims to generate detailed estimates of the recurrent and capital costs of the routine NIP in Honduras. Additionally, this study will provide some information on the cost of new vaccine introduction for the 13-valent pneumococcal conjugate vaccine relying primarily on central level data. Furthermore, this study will help map the financial resources used for immunization, identifying the different sources and flows of financial contributions to immunization activities in Honduras at the central, regional and health facility levels.
The Ministry of Health, Trinidad and Tobago has expanded the National Immunization Programme with the introduction of the Human Papillomavirus Vaccination (HPV), with an official launch by the Hon. Minister of Health, Dr Faud Khan, late last year.
On 14-15 November 2012, members of the International Expert Committee (IEC) for documenting and verifying the elimination of measles, rubella and congenital rubella syndrome (CRS), visited Haiti. The president of the Na-tional Elimination Commission presented evidence supporting the interruption of the circulation of endemic mea-sles and rubella viruses in a technical meeting with the national authorities, external measles and rubella subject-matter experts and strategic immunization partners. Posters from the ten departments, which highlighted the country experience in implementing the campaign, were also presented.
In 2011, Bolivia initiated a measles-rubella follow-up campaign as part of its strategy to maintain measles and rubella elimination in the Region of the Americas and in response to the risk of virus reintroduction due to large outbreaks in Europe and Africa. Bolivia set a goal to vaccinate: 917,546 children aged two-five years old; all women aged 22-44 years old that were not vaccinated during the "speed-up campaign" of 2006 because of pregnancy; health care work-ers; and personnel in contact with tourists and travelers (airports, hotels and transportation terminals).
Bolivia, Haiti, Honduras and Nicaragua received awards for their immunization achievements during the GAVI Alliance Partners’ Forum, held in Dar es Salaam, Tanzania on 5-7 December 2012.
Location: Buenos Aires, Argentina
Dates: 10-12 September 2012
Participants: Representatives of nine out of the 11 polio laboratories in the Region, as well as the United States Centers for Disease Control and Prevention (CDC), World Health Organization (WHO) and PAHO’s Immuniza-tion Programme participated in the meeting.
Purpose: The main objectives of the meeting were to: review the status of the Polio Laboratory Network of the Americas; review and discuss recent advances in virological and molecular methodologies used in the Global Polio Laboratory Network (GPLN); and discuss issues relevant to the functioning of the Pan American Health Organiza-tion (PAHO) Laboratory Network and the management of laboratories.
Location: Buenos Aires, Argentina
Dates: 8-9 November 2012 Participants: Eighteen experts from four Latin American countries (Argentina, Bolivia, Brazil and Colombia), the US Centers for Disease Control and Prevention (CDC), the Australian HPV vaccination programme and cancer registry, WHO and PAHO contributed to this consultation.
Purpose: To examine the report of a 2009 World Health Organization (WHO) meeting on a similar subject; share existing country plans and experiences; identify national capacities and opportunities for the surveillance of HPV-related diseases and HPV diagnostics; and outline the necessary steps toward the completion of a Regional proposal.
Location: Santa Cruz, Bolivia
Dates: 30-31 October 2012 Participants: Nineteen participants representing six countries (Argentina, Bolivia, Brazil, Colombia, Honduras, and Panama), the International Planned Parenthood Federation, the World Health Organization (WHO) and PAHO.
Purpose: The workshop objectives were to share national and subnational experiences in the introduction and implementation of HPV vaccine; identify strengths and weaknesses of managerial, oper-ational and logistical processes specific to immunization pro-grammes; establish the integration level with cervical cancer pre-vention and adolescent health programmes and existing opportuni-ties; and define lessons learned for other countries in the Region considering HPV vaccine introduction.
Members of the International Expert Committee (IEC) for Measles and Rubella Elimination in the Americas, exter-nal experts from other agencies, and the Pan American Health Organization’s (PAHO) regional advisor for measles and rubella visited Argentina, Colombia, and Haiti to conclude the process of documenting and verifying the elimina-tion of endemic measles, rubella and congenital rubella syndrome (CRS) in the Region. The main objective of the visits was for the IEC to independently evaluate if the interruption of measles and rubella endemic transmission has been achieved in each country, recommend necessary revisions, and provide suggestions on additional measures for overcoming the remaining barriers in maintaining the interruption of measles and rubella transmission.
The Immunization in the Americas brochure is published every year by the Comprehensive Family Immunization Project of the Pan American Health Organization (PAHO). Its objective is to highlight the key data on vaccine-preventable diseases and the provision of immunization services in the countries of the Americas.
Haiti’s Ministry of Public Health and Population, the Pan American Health Organization (PAHO/WHO) and the Centres for Disease Control and Prevention (CDC) conducted a successful symposium in Haiti entitled, "Introduction of New Vaccines in Haiti’s Immunization Programme."
The sixth annual Mini EPI-Managers Meeting of the Dutch Caribbean was held in Sint Maarten, from 13-14 September 2012. The "mini-meeting" presented an opportunity for EPI managers from each island, to come together with representatives of the Immunization Department of the National Institute for Public Health and the Environment in the Kingdom of the Netherlands, to share experiences regarding their respective immunization programmes, strengthening inter-island collaboration to guarantee uniformity in programmes and create synergies between the EPI programmes of the Dutch Caribbean and of the Netherlands.
The Twentieth Meeting of the Pan American Health Organization’s (PAHO) Technical Advisory Group (TAG) on Vaccine-preventable Diseases was held from 17-19 October 2012 in Washington, D.C. Participants included focal points from PAHO’s country offices, US Centres for Disease Control and Prevention (CDC), Bill and Melinda Gates Foundation, World Health Organization (WHO), WHO-EMRO, Médecins Sans Frontières/Doctors With-out Borders, GAVI Alliance, UNICEF, among others.
Dr Cláudio Marcos da Silveira, a Brazilian epidemiologist who played an important role in the implementa-tion of immunization programs in the Americas, passed away on 28 August 2012 after losing a battle with cancer. During his years working for the Pan American Health Organization (PAHO), he collaborated in the development and implementation of several immunization strategies that resulted in the regional control and elimination of various vaccine-preventable diseases, notably the regional elimination of polio and measles, and was one of the main architects of the strategy that eliminated neonatal tetanus as a public health problem in most countries of the Americas.
For more information on Dr da Silveira’s life, please visit this link.
Published in Global Immunization Newsletter, October 2012.
From 1-9 October 2012, the Dominican Republic implemented a study, with support from the Pan American Health Organization (PAHO), to assess missed vaccination opportunities in hospitals and health centres across the country in order to identify fac-tors contributing to low coverage levels in high-risk municipali-ties (DPT3 coverage < 85%). The results of the study will help develop and implement interventions in the short and long-term.
From 24-28 September 2012, the ProVac Initiative led a planning mission to Honduras to begin preparations for a comprehensive costing study of the routine Expanded Programme on Immunization (EPI). Honduras has introduced rotavirus in 2009 and pneumococcal conjugate vaccines in 2011 with support from the GAVI Alliance. In preparation for its upcoming GAVI-graduation, the country has requested support from the Pan American Health Organization’s (PAHO) ProVac Initiative to explore routine programme costs and financial flows to better inform long-term financial sustainability plans.
A comprehensive international evaluation of Colombia’s Expanded Programme on Immunization (EPI) took place from 27 August-7 September 2012. The evaluation of the data quality component of the EPI evaluation started earlier, on 23 August 2012, as it was a full data quality self-assessment (DQS) including a review of the national immunization registry being rolled-out in the country. The primary objective of the international evaluation was to: assess the organization, structure, and operation of the national EPI to maintain achievements in the elimination of some vaccine-preventable diseases (VPDs); address the unfinished immunization agenda by making the benefits of vaccination available to all; and, address new challenges such as the introduction of new vaccines. Evaluators visited six departments and the capital district of Bogotá, 24 municipalities, and 53 health care centres (public and private), and performed 686 interviews. Of those interviewed, 85 were from the political spheres, 65 EPI managers, over 100 managers from other programmes or representatives of cooperation agencies or institutions, and 383 users.
The Uru Chipaya Ethnic Group of the Oruro Department of Bolivia received the 2011 Pan Ameri-can Health Organization (PAHO) Immunization Award for their activities to keep immunization coverage close to 100% in their area. The group was presented with a certificate of recognition, as well as a monetary gift in the amount of three thousand US dollars at the twentieth Meeting of PAHO’s Technical Advisory Group (TAG) on Vaccine-preventable Diseases on 17 October 2012 in Washington, D.C (article in this issue of the GIN). PAHO created the Immunization Award to recognize outstanding contributions to a national immuniza-tion programme and to the control and/or elimination of vaccine-preventable diseases.
Representatives from Brazil, Chile, the city of Bogotá-Colombia, Honduras and Uruguay presented their experi-ence developing and using their computerized immunization registries at the first national meeting of the American Immunization Registry Association (AIRA) in St Paul, Minnesota on 19-20 September 2012. Also, a representative from the Immunization Programme of the Pan American Health Organization (PAHO) was invited to present an overview of the status of implementation of national immunization registries in Latin America.
In August 2012, Colombia’s Ministry of Health and Social Welfare introduced the human papillomavirus (HPV)vaccine into its national immunization schedule in order to significantly reduce the incidence of cervical cancer. Following an analysis of the current evidence available and a cost-effectiveness study of HPV vaccines, the MoH’s National Immunization Technical Advisory Group (NITAG), along with the Colombian Federation of Obstetrics and Gynaecology, the Colombian Society of Paediatrics, the Colombian Federation of Perinatology, the National Institute of Health and the National Institute of Oncology, agreed to recommend including the HPV vaccine in its national immunization schedule.
On 20 September 2012, ministers of health of the Region approved an emergency plan of action to keep the Americas free of measles, rubella, and congenital rubella syndrome (CRS) at the 28th Pan American Sanitary Conference. Given the continuing circulation of measles and rubella viruses in other regions of the world, countries of the Region continue to be exposed to high risk of virus importations. Moreover, some countries have reported weaknesses and failures in their national surveillance systems and routine immunization programmes, making them vulnerable to the reintroduction of viruses that can cause outbreaks.
A new PAHO coffee table book entitled, Vaccination: An Act of Love — 10 years of Vaccination Week in the Americas, was launched on 18 September 2012 during the 28th Pan American Sanitary Conference.
From 10-14 September 2012, a meeting was held in the city of Bogota, Colombia. The objectives of the yellow fever meeting were to provide an update on the prevention and control of the disease, diagnosis methods,research and management of adverse events, as well as crisis management and risk communication. Participants also reviewed the epidemiological situation of yellow fever in the Americas, outbreaks in selected countries, and vaccination plans for yellow fever.
Between 26 July-10 August 2012, a pilot of the new GAVI Alliance Immunization Data Quality Assessment tool (IDQA) was conducted in Bolivia. The assessment team included members from the Bolivian MoH, GAVI, the US Centers for Disease Control and Prevention (CDC) and the PAHO. Two previous pilot activities have been performed in 2012 in Ghana and Uganda. The objective of this activity was to field test the IDQA protocol developed in 2011, in collaboration with an ad hoc task team in a Latin American country, in order to assess the capacity of the tool for diverse country-specific settings and inform the use of the IDQA rollout, expected in 2013. Bolivia has had an excellent record in immun-ization data quality, as evidenced by results from a data quality assess-ment performed in 2010, as part of an EPI evaluation conducted by PAHO.
In June, Haiti’s Ministry of Public Health and Population successfully concluded its intensive health activities focused on children. A total of 3,045,529 Oral Polio Vaccine (OPV) doses were administered to children aged nine years or less and 2,938,863 Measles/Rubella (MR) vaccine doses were administered to children aged between nine months and nine years. Likewise, a total of 1,210,438 vitamin A capsules were administered to children aged between six months and six years as well as 1,352,789 albendazol tablets to children aged two to nine years.
From 9-12 July 2012, an international workshop on cold chain operations was held in Managua, Nicaragua. The main objective of the workshop was to train EPI managers and cold chain managers on cold chain operations. Other workshop objectives included providing knowledge on the use of new tools and technologies, presenting guidelines for effective management of cold chain operations and to draw on regional experiences to homologize the text in the cold chain module that PAHO is updating. The purpose of PAHO’s Cold Chain Module is to help countries plan cold chain and supply chain operations for five to ten years from now, for both the introduction of new vaccines and supporting a growing population. The new Unit Five in the Cold Chain Module emphasizes management practices.
On 4 July 2012, the Dominican Republic introduced the rotavirus vaccine into its national immunization schedule in order to prevent diarrhea in children and avoid mortality. The introduction of the vaccine was announced at the official launch in the Santo Socorro hospital. The first doses were administered by the Minister of Health, Dr Bautista Rojas Gomez and the Regional Director of the Pan American Health Organization (PAHO), Mirta Roses to two children aged two months (photo).
According to Dr Rojas Gomez, the new vaccine will prevent the diarrheal infec-tion that affects virtually all children in the first five years of life. The Minister explained that the administration of this oral vaccine in all vaccination posts in the country will also reduce paediatric visits and congestion in hospitals. Dr Ro-jas Gomez also stated that with the addition of the Dominican Republic, more and more countries in Latin America include this vaccine in their immunization programmes, which he assured is a great achievement.
On 6 June 2012, the results of a vaccination coverage survey were presented to the Minister of Health and other health officials in El Salvador. The survey was requested by El Salvador’s EPI, designed with support from the Pan American Health Organization and implemented in partnership with a local university with ex-perience in conducting (non-health related) surveys. A survey to assess vaccination coverage for vaccines recommended for children aged under two had been recommended during the country’s 2009 EPI evaluation, as problems detected for numerators and denominators were affecting administrative coverage calculation. The survey included 2,550 children aged 24-59 months at the time of the interview (Nov-Dec 2011) living in the five Health Regions of the country. The main objectives were to determine vaccination coverage for BCG; first, second and third dose of DTP-Hib-HepB and OPV; the first and second dose of Rotavirus; the first dose of MMR; and the first booster of DTP and OPV; to estimate vaccination timeliness, in relation to the recommended age; to compare survey coverage with administrative coverage; and to identify reasons for not having received some vaccines.
VINUVA (from "New Vaccines Surveillance" in Spanish) was created by the Pan American Health Organiza-tion (PAHO) in 2011 to provide a standardized computerized tool for the countries in the Region of the Americas that are part of the rotavirus and invasive bacterial disease surveillance network. The VINUVA workshop was held on 5-6 June 2012 in Paramaribo, Suriname for Caribbean countries that are part of the rotavirus diarrheal surveillance network. The objectives of the workshop were to discuss the new surveil-lance reporting processes between the Caribbean Epidemiology Centre (CAREC) and its reporting countries; discuss the required surveillance indicators; identify the person in each hospital responsible for the monthly recording of the surveillance data in VINUVA; identify the person per country responsible for verifying and approving the surveillance data; and train participants in using the VINUVA tool.
Thanks to the recognized success of PAHO’s ProVac Initiative in coun-tries of the Americas, a ProVac International Working Group (IWG) was established to share ProVac tools and methodologies with other Regions. During the two-year pilot phase, this Bill and Melinda Gates Foundation funded project will serve as the platform through which ProVac tools and methodologies developed and implemented in PAHO-countries can be tested and adapted to other regional contexts. The ProVac IWG is con-formed of multiple partners. PAHO’s ProVac Initiative will serve as the secretariat and coordinating agency. Agence de Médecine Préventive (AMP) and PATH will serve as implementing agencies by providing direct technical assistance to country teams using ProVac’s tools and methods. They will provide support for cost-effectiveness evaluations of potential new vaccine introductions in three AFRO countries, two EMRO coun-tries, and two EURO countries and will hold a workshop in each of the before mentioned Regions.
From 21-25 May 2012, participants from selected countries of the
On 10 May, public health officials from across the
On 26-29 March 2012, the fourth International workshop on Good Practices for Safe Injection and a Course on Cold Chain Operations and Maintenance were held in Tegucigalpa, Honduras. The purpose of the Workshop was to train and update health professionals on safe injection practices, new technologies, good storage practices, and preventing risks associated with needle accidents.
From 9-18 May 2012, the local Regional Health Agency and PAHO jointly evaluated the immunization programme of the French Department of Guyane. French Guiana is located in the North-east of South America and shares borders with
This year marks two milestone events in public health: the 10th anniversary of Vaccination Week in the Americas (VWA), and the 1st ever World Immunization Week (WIW). In the Americas, over the last ten years, VWA has grown to become the largest multinational health initiative in the Region, thanks to the political commitment of governments and the dedication of the Region’s health care workers. The objectives of Vaccination Week are: 1) to advance equity and improve access to vaccination for people of all ages through outreach to underserved and marginalized communities; 2) increase vaccination coverage of all antigens to prevent disease outbreaks; 3) raise awareness on how immunization saves lives; 4) to maintain the topic on the political agenda; and 5) to promote the transition from child to family immunization.
The International Expert Committee (IEC), responsible for documenting and verifying the elimination of measles, rubella and congenital rubella syndrome (CRS) in the Americas, met on 29-30 March 2012, at the Pan American Health Organization/World Health Organization (PAHO/WHO) headquarters. The objective of the meeting was to assess the progress achieved on this topic and to define the road map to sustain the elimination of these diseases in the Region. The Presidents and members of National Commissions along with health authorities from countries that reported sustained measles outbreaks and rubella cases in 2011 were also convened for an ad-hoc meeting with the IEC.
On 20-21 March 2012, PAHO immunization project conducted a workshop in Buenos Aires, Argentina to identify lessons learned from the introduction of the pneumococcal conjugate vaccine (PCV) in Latin America and the Caribbean (LAC). Some of the meeting objectives were to share experiences between countries with different scenarios and vaccination schedules as well as to identify the strengths, opportunities and problems that arose in the logistic and operational process of the PCV introduction. The workshop also discussed the critical aspects of the PCV introduction in order to support the introduction process in other countries of the Region and other WHO Regions.
Senior Advisor, Dr Cuauhtémoc Ruiz Matus and Regional Advisor, Dr Mauricio Landaverde of PAHO’s Comprehensive Family Immunization Project, along with select participants of Latin American countries conducted a review of the current situation of whooping cough and of the strategies recently implemented in some of the countries of the Region in order to mitigate the outbreaks and the case-fatality of this vaccine-preventable disease.
On 22-23 March 2012, the Pan American Health Organization’s (PAHO) ProVac Initiative held an "experience sharing workshop" on the use of the CERVIVAC model (a ProVac tool for cost-effectiveness analysis of the Human Papillomavirus (HPV) vaccine and cervical cancer screening strategies), in Buenos Aires, Argentina. Eight country teams, comprised of EPI managers, cervical cancer programme managers, PAHO Immunization focal points, health economists and other professionals, participated in the meeting.
The 28th meeting of the Caribbean Expanded Programme on Immunization (EPI) managers was held in Bridgetown, Barbados, 27 February-2 March 2012. The meeting convened over 120 participants from 30 countries, as well as representatives from international agencies such as the US Centres for Disease Control and Prevention (CDC) and the Canadian Public Health Agency (CPHA). Participants included representatives from the Ministries of Health, the Pan American Health Organization/World Health Organization (PAHO/ WHO), and the Caribbean Epidemiology Centre (CAREC).
Over 275,000 (not 500,000) women die annually from cervical cancer worldwide. In the Americas, the Caribbean sub-region has the fourth highest cervical cancer incidence in the world. Achieving high coverage of secondary preventive strategies, such as cytology, to detect precancerous lesions in women has proved challenging in Latin America and Caribbean (LAC). A safe and efficacious vaccine to prevent the sexually transmitted human papillomavirus (HPV) infection, a leading cause of cervical cancer in women, is now licensed for use in young girls.
During the second week of February, the ProVac team initiated and concluded a cost-effectiveness analysis (CEA) of the pneumococcal conjugate vaccines (PCV) in Peru and El Salvador, respectively.
Haiti’s Ministry of Public Health and Population is working to implement intensified vaccination activities nationwide in 2012. The country will implement a first round of vaccination using measles-rubella vaccine (RR) and OPV for children aged <=9 years (9 months to 9 years for RR) in April and a second vaccination round using polio (and Td for the elimination of neonatal tetanus) at least one month after finishing the first. Vitamin A supplements and deworming will be integrated. These supplementary immunization activities (SIA) represent a unique opportunity to strengthen Haiti’s regular immunization program, while achieving a rapid increase in vaccination coverage against polio, measles and rubella.
Regional Office for the Americas of the World Health Organization