Integration: Leveraging Immunization for Health System Strengthening

A baby is being vaccinated

The battle to eliminate polio is one example of how immunization integration can be leveraged to strengthen health systems and build vaccine acceptance. Integration is one of the three pillars of the Endgame Strategy and is highlighted as a strategic priority in the Immunization Agenda 2030 (IA2030) and in Gavi’s 5.0 strategy.

Immunization programs are among the most successful and important public health programs across the globe, reaching an estimated 85% of the world’s children1. Although immunization programs like the Expanded Programme on Immunization (EPI) successfully reach the majority of the world’s children, other important health interventions may lack delivery mechanisms with the same scale as immunization. According to the CDC, “immunization reaches more children than any other single intervention.”2 The success of immunization programs means that they can also become an important platform for delivering additional health resources and services.

In many circumstances, populations may have particularly limited access or contact with services to address health issues such as malnutrition and vitamin deficiencies, malaria, access to family planning, and early infant diagnostics for HIV. Effective immunization integration can help strengthen health systems, providing more efficient and accessible health care for women and children.

The battle to eliminate polio is one of the examples for how immunization integration can be leveraged to strengthen health systems, particularly in the most vulnerable areas. Integration is one of the three pillars of the Endgame Strategy and is highlighted as a strategic priority in the Immunization Agenda 2030 (IA2030) and in Gavi’s 5.0 strategy to ensure no one is left behind with immunization.

The Integration Continuum

There are many possible permutations of integrated health services. The WHO recommends that integration be viewed as a continuum of potential options, rather than as zero-sum options of “integrated” and “not integrated.”  There are many different factors3 that need to be taken into account to determine the optimal strategy for integration of immunization services such as:

  • selecting interventions that can be feasibly integrated;
  • coordination across program levels;
  • ensuring adequate training and workload for health workers;
  • ensuring the participation of community based organizations, leaders, and volunteers
Continuum of Immunization Strategies

Integration and Community Acceptance of Vaccines

With vaccine hesitancy becoming a rising global threat, community engagement should serve as a cornerstone to the implementation and planning of health services. The co-delivery of immunizations with services that are prioritized by the target community can improve acceptability. Co-delivery of vaccines with priority services can also improve job satisfaction for frontline health workers by allowing workers to provide the range of services desired by community members. When community health workers in parts of India and Nigeria focused only on providing repeated polio campaigns, they were questioned by the community about why they only addressing a single disease that wasn’t a priority for many individuals in the area4.

“When talking about healthcare services in urban slums, an interviewee described that, ‘it’s not a matter of hard- to- reach but rather, hardly reached.’ Communities felt ignored by their government, and were thus mistrusting and sceptical of government or NGO intervention during polio vaccination rounds.”

Bellatin A, Hyder A, Rao S, et al. (2021)

In an investigation of 30 years of polio campaigns in Ethiopia, India, and Nigeria, researchers found that in all study countries, community hesitancy towards vaccines could be mitigated when health systems demonstrated responsiveness to the community’s priorities and needs4.

  • Among pastoralist communities in East Africa, co-delivery of polio vaccines along with high-priority services like veterinary care, improved community acceptance of the vaccines5.
  • In Ethiopia and Nigeria, OPV was increasingly delivered alongside Vitamin A, insecticide- treated nets, and deworming tablets, and CORE group volunteers engaged broadly in child health education6,7.
  • India’s 107 Block Plan, developed in 2009, focused on routine immunization, sanitation8 practices, breastfeeding rates, and reducing diarrheal disease. One of major challenges in the final years of polio elimination in India was resistance from vaccine hesitant groups. One factor for successful elimination of polio in Uttar Pradesh was improving vaccine acceptance by packaging other basic healthcare services such as routine check- ups and essential medications9.

Evidence from the VoICE Compendium

The integration of maternal and child health interventions into immunization campaigns can lead to improved rates of immunizations and related healthcare interventions.

In an effort to reach children with vitamin A deficiency in the African countries of Angola, Chad, Cote d’Ivoire, and Togo, vitamin A supplementation was administered during Polio vaccine campaigns. This led to a minimum coverage of 80% for vitamin A and 84% for polio vaccine in all of the immunization campaigns. During the second year of vitamin A integration into the polio vaccination campaign, coverage exceeded 90% for both vitamin A and polio vaccination in all four countries.

Immunization services can be integrated with family planning services to strengthen healthcare access for children and parents.

The total number of women accessing family planning services during the study period increased by 14% while DPT immunization rates for children remained consistent. In interviews, parents and providers found the integration of family planning and immunization services to be feasible and beneficial, indicating a win-win for both services.

Recent assessments of missed opportunities for vaccination (MOV) demonstrate that immunization coverage rates may also benefit from increased integration.

Children attending health facilities for vaccination, clinical care or other reasons, were not consistently being offered all of the recommended vaccines (57% for all clinic attendees, 25% for children attending for vaccination and 89% among those attending for medical consultation). Integrating immunization into primary care visits, health registers, and workflows can help reduce missed opportunities for vaccination.

Immunization programs provide opportunities for cost-sharing and external funding when used alongside other health interventions.

BCG and DPT have the highest coverage of any vaccines worldwide and are typically administered within 6 weeks of birth. This timing offers the opportunity to deliver a range of early childhood development interventions such as newborn hearing screening, sickle cell screening, treatment and surveillance, maternal education around key newborn care issues such as jaundice, and tracking early signs of poor growth and nutrition.

Integration in the COVID-19 Era: Opening New Doors

“…as billions of dollars are being spent to support vaccine rollout, as much as possible, these funds should be used in ways that not only distribute vaccines as quickly and equitably as possible but also strengthen – rather than detract from – underlying PHC systems.”

The impacts of the COVID-19 pandemic may present an opportunity for new ways of working across health campaigns, including promising applications of integration. The Primary Health Care Performance Initiative (PCPPI) has published a brief summarizing how the roll-out of COVID-19 vaccination efforts can be leveraged to support long-term primary health care strengthening.

  1. Building systems for population health management
  2. Strengthening surveillance and information systems
  3. Formalizing mechanisms for multi-sectoral action and social accountability
  4. Strengthening quality management infrastructure and building sustainable supply chains
  5. Sustaining investments in the health workforce

recent report published by WHO comprehensively documents the significant role played by polio eradication personnel during the pandemic, and urges strong action to sustain this network to deliver essential public health services after polio is eradicated.

Integrating with Intention

Simply integrating immunizations with other services is not sufficient to add value: It’s also key that integration must be implemented thoughtfully with appropriate attention paid to the context at hand. Well-integrated immunization programs can:

  • Improve efficiency and reduce redundancy for frontline workers – saving them valuable time.
  • Improve equity and coverage
  • Improve community vaccine acceptance

Implementation Glossary

Integrated  Service  Delivery – the  organization  and  management  of  health  services  so that  people get the  care they need, when they  need  it, in  ways  that  are  user-friendly,  achieve  the desired results and provide value for money.

Integration – The sharing of all or specific campaign components or functions by a specific program addressing a disease or health need with the broader health system and ongoing delivery of interventions through general health services.

Full Integration – Involves sharing of both operational and administrative functions and responsibilities and delivery of campaign interventions via primary health care (PHC). It occurs when interventions that were formerly delivered via independent health campaigns are delivered at the PHC level with other ongoing health services.

Partial Integration – Partial integration refers to a spectrum or continuum, in which campaigns share different operational and/or administrative components with any of the PHC system elements per the modified PHCPI framework—at the systems or inputs levels or both, while continuing to deliver services independently.

Health Campaign – A coordinated set of activities that targets resources to achieve a specific health goal or goals and is typically time-limited.

Collaboration of Campaigns – Partial integration of specific campaign components between vertical health programs (targeting different health problems) to improve efficiency and effectiveness of the vertical programs, but without co-delivery of interventions at the same service delivery points.

Periodic Intensification of Routine Immunization (PIRI) – A format with a range of options falling between the poles of routine services and campaigns. PIRI activities are intended to augment routine immunization services rather than be the primary means of providing it.


  1. PMNCH Knowledge Summary #25 Integrating immunization and other services for women and children. WHO. 2013.
  2. CDC. CDC Global Health – Immunization – Reaching Every Child. Published May 21, 2019.
  3. World Health Organization. Working Together: An Integration Resource Guide for Immunization Services throughout the Life Course. World Health Organization; 2018.
  4. Neel AH, Closser S, Villanueva C, et al. 30 years of polio campaigns in Ethiopia, India and Nigeria: the impacts of campaign design on vaccine hesitancy and health worker motivation. BMJ Global Health. 2021;6(8):e006002. doi:10.1136/bmjgh-2021-006002
  5. Haydarov R, Anand S, Frouws B, Toure B, Okiror S, Bhui BR. Evidence-Based Engagement of the Somali Pastoralists of the Horn of Africa in Polio Immunization: Overview of Tracking, Cross-Border, Operations, and Communication Strategies. Global Health Communication. 2016;2(1):11-18. doi:10.1080/23762004.2016.1205890
  6. Asegedew B, Tessema F, Perry HB, Bisrat F. The CORE Group Polio Project’s Community Volunteers and Polio Eradication in Ethiopia: Self-Reports of Their Activities, Knowledge, and Contributions. The American Journal of Tropical Medicine and Hygiene. 2019;101(4_Suppl):45-51. doi:10.4269/ajtmh.18-1000
  7. Bawa S, McNab C, Nkwogu L, et al. Using the polio programme to deliver primary health care in Nigeria: implementation research. Bull World Health Organ. 2019;97(1):24-32. doi:10.2471/BLT.18.211565
  8. Sukla P, Sharma KD, Rana M, Zaidi SHN. Polio eradication in India: New intiatives in sanitation. Indian J Community Health. 2013;25(1):74-76.
  9. Bellatin A, Hyder A, Rao S, Zhang PC, McGahan AM. Overcoming vaccine deployment challenges among the hardest to reach: lessons from polio elimination in India. BMJ Glob Health. 2021;6(4):e005125. doi:10.1136/bmjgh-2021-005125

World Immunization Week 2020 Social Media Toolkit

VoIce banner for World Immunization Week 2020

World Immunization Week 2020 (April 24-30) is an opportunity for immunization advocates across the world to promote the value of vaccines for protecting people of all ages against preventable diseases. Our VoICE social media toolkit provides messaging on the vital role that vaccines play in global health. Beyond saving millions of lives every year #VaccinesWork For All by strengthening our health care systems, protecting global health security, shrinking equity gaps, and more.

Join us in promoting the message that #VaccinesWork For All by sharing the evidence on the broad benefits of immunization!

VoICE Social Media Toolkit for World Immunization Week 2020

Download the VoICE World Immunization Week 2020 Toolkit for a series of social media messages and shareable images that highlight key evidence on the value of vaccines! Messaging covers the six main topics of the VoICE Compendium: Health, Education, Economics, Equity, Health Systems and Integration, and Global Issues.

The toolkit is also available as a downloadable PDF and all images can be easily copied or saved directly from this page.

Welcome to WIW 2020!

Immunization saves millions of lives every year. Yet, there are still nearly 20 million children worldwide who are not getting the vaccines they need.

We have it in our power to close this gap!

Welcome to World Immunization Week banner


#DYK those with HIV, cancer, and weakened immune systems benefit from immunization of others through herd immunity?

Herd Effects Children banner

#VaccinesWork for all by protecting people around us, especially those who are vulnerable like new babies, older adults, and people who are seriously ill.

Herd Effects All Ages banner 2

Malnourished kids suffer the most from pneumonia, diarrhea and other vaccine-preventable infections.

It’s time to level the playing field!

Undernutrition cycle


#DYK that immunization is linked to improved education and cognitive outcomes? Immunized children stay healthier so they miss less school and attain higher school grades.



Vaccines don’t just save lives; they keep the world’s most vulnerable people out of poverty. A 2018 @Health_Affairs study found the poorest households receive the most benefit from increased access to vaccines.

Policy Poverty Quote

Studies show that vaccines can help stop poverty in addition to saving lives. Read the latest research on the economic benefits of vaccines.

#VaccinesWork for All

Prevent Poverty banner


13.5 million children around the world still can’t access vaccines – these children are often the most vulnerable to disease and health disparities. We have it in our power to close this gap!

Leaving no child behind means ensuring the most marginalized – those touched by conflict or forced from their homes – have access to lifesaving #vaccines.

Vaccines are a tool for reducing gender, geographic, and sociocultural inequity – find the latest evidence on immunization and equity on VoICE:

Immunization For Equity


Immunization can decrease hospital admissions, thus alleviating pressure on overburdened health systems, freeing up needed medical resources.

In Kenya, rates of pneumonia hospitalizations in children <5 dropped by 27% after 4 years of PCV10. #VaccinesWork for All to reduce hospital admissions and free up more resources to treat and prevent other illnesses.


Between 2005-2014 nearly 400 infectious disease outbreaks (excluding measles) were reported to the @WHO, threatening the health security of the entire world.

View @Voice_Evidence’s feature issue on #outbreaks to learn more:

Immunization Outbreaks banner

2019 saw a record for measles outbreaks – more than 140,000 lives were lost, mostly children.

Measles is so contagious that the exposure of a single person without immunity to the virus can spark an outbreak that quickly burns through whole communities.

Universal Health Coverage: What immunization advocates should consider

December 12th is worldwide Universal Health Coverage (UHC) day! Although exceedingly complex in its implementation, the concept behind UHC is simple: All people should benefit from quality health services, medicines and vaccinations, and no one should be put in financial peril to do so. In recognition of UHC Day 2018, the VoICE team brings you a brief look at the interplay between coverage of immunization and other basic health interventions, and the important role of immunization in protecting against financial risk – both within the context of the Sustainable Development Goal Target for UHC.

A selection of VoICE evidence in this issue

Hinman, A.R., and McKinlay, M.A. 2015. Immunization equity. Vaccine. 33(2015).

Chebab, E.T., et al. 2016. Experience of integrating vitamin A supplementation into polio campaigns in the African Region.. Vaccine. 34(43).

Torres-Rueda, S., Rulisa, S., Burchett, H.E., et al. 2016. HPV vaccine introduction in Rwanda: Impacts on the broader health system. Sexual and Reproductive Healthcare. 7.

Niessen, L., ten Hove, A., Hilderink, H., et al 2009. Comparative impact assessment of child pneumonia interventions. Bulletin of the World Health Organization. 87.

Deoganakar, R., Hutubessy, R., van der Putten, I., et al 2012. Systematic review of studies evaluating the broader economic impact of vaccination in low and middle income countries. BMC Public Health. 12(878).

Olusanya, B.O. 2009. Optimising the use of routine immunisation clinics for early childhood development in sub-Saharan Africa. Vaccine. 27.

Restrepo-Mendez, M.C., Barros, A.J., Wong, K.L.M., et al. 2016. Missed opportunities in full immunization coverage: findings from low- and lower-middle-income countries. Global Health Action. 9(1).

Verguet, S., Memirie, S.T., and Norheim, O.F. 2016. Assessing the burden of medical impoverishment by cause: a systematic breakdown by disease in Ethiopia. BMC Medicine. 14(1).

Chang, A.Y., Riumallo-Herl, C., Perales, N.A., et al. 2018. The equity impact vaccines may have on averting deaths and medical impoverishment in developing countries. Health Affairs. 37(2).

Key Points 

  1. Achieving universal coverage of basic health services will require strengthening and expanding current health systems AND new approaches to reaching those who still cannot or do not access health services.
  2. The reach of immunization delivery programs can be leveraged to provide other basic services – and increase financial efficiency of health systems – and the reverse is also true: the delivery of other interventions can help to increase the uptake of vaccines.
  3. Achievement of UHC will positively contribute to at least six of the 17 Sustainable Development Goals.
  4. Immunization can contribute significantly to achieving financial risk protection against health costs.

Universal Health Coverage and the Sustainable Development Goals

December 12th is worldwide Universal Health Coverage (UHC) day!  The aim of drawing attention to this day is to shine the global spotlight on the gaps in achieving health as a human right. Although exceedingly complex in its implementation, the concept behind UHC is simple: All people should benefit from quality health services, medicines and vaccinations, and no one should be put in financial peril to do so.

In 2015, 193 United Nations Member States committed to an ambitious set of 17 “Sustainable Development Goals” (SDGs) by 2030. The right to health not only figures prominently as a goal in and of itself – SDG3 is to “Ensure healthy lives and promote well-being for all at all ages” – but is also fundamentally intertwined with goals related to equity, poverty, economic growth and inclusion. (See Figure 1.)

Figure 1: The interrelatedness of Universal Health Coverage with other Sustainable Development Goals, and the importance of health systems strengthening.

Source: Tracking Universal Health Coverage: 2017 Global Monitoring Report. World Health Organization and International Bank for Reconstruction and Development / The World Bank; 2017. License: CC BY-NC-SA 3.0 IGO. Available here:

Embodied in the 8th Target of  SDG3 (SDG 3.8), the pursuit of UHC is supported by the twin indicators of 1) coverage of essential services (including immunization), and 2) financial risk protection from the incurrence of economically burdensome health costs.  In recognition of UHC Day 2018, the VoICE team brings you a brief look at the interplay between coverage of immunization and other basic health interventions, and the important role of immunization in protecting against financial risk – both within the context of SDG 3.8.

Building on coverage of vaccines gives UHC a head start, but there is more to do

Equity is at the heart of the Sustainable Development Goal target 3.8, which seeks to achieve universal health coverage and financial risk protection for all.  The coverage indicator for the achievement of UHC tracks the coverage of 14 “tracer interventions”, which together serve as a barometer for access to basic health services. Access to immunization is tracked through the coverage of the third dose of DTP3, one of four maternal and child health tracer interventions. Although DTP3 coverage is evidence of the fact that immunization is one of the most widely available and equitably distributed interventions worldwide, several other important vaccines lag behind the 85% coverage of DTP3 worldwide in 2017.

Specific vaccines notwithstanding, high coverage with some vaccines such as DTP make immunization programs a critical backbone of any universal health coverage strategy. Routine and campaign-based immunization programs reach some children in remote or poverty stricken areas whose families have little other connection to the health system, and as such, offer opportunities to provide additional basic health care services to children and their families, especially interventions associated with maternal and child health. See Figure 2 for some highlights from VoICE of the opportunities for mutual reinforcement between immunization and other programs.

Figure 2: Examples of the integration of immunization and other health services.

Vitamin A distribution integrated with polio vaccine campaigns led to increased VitA coverage in several African countries.

Delivery of HPV vaccine to school-age girls in Rwanda provided an opportunity to offer school-age boys a variety of health services at the same time.

The timing of childhood immunizations could be harnessed to deliver a range of early childhood development interventions such as newborn hearing screening, sickle cell screening, treatment and surveillance, maternal education around key newborn care issues such as jaundice, and tracking early signs of poor growth and nutrition.

Despite the relatively high coverage globally of some vaccines, other critical vaccines have reached only a small fraction of the world’s children. Fully 15% of the world’s children are not reached at all by immunization – a gap whose distribution carries significant inequity – so vaccine coverage successes are very much tied to the achievement of UHC goals and targets for other health services.

The achievement of UHC targets will, however, require significant reform and expansion of existing health systems to address challenges such as missed opportunities to integrate services. For example, a recent study in 14 low- and middle-income countries found an exceedingly high rate of missed opportunities to vaccinate in 8 of the 14 countries, despite families coming into contact with the health system. For these countries, children failed to be vaccinated more than 50% of the time, despite they or their mother having received at least one of 5 other basic health interventions provided through the health system. Additionally, for the millions of families not reached at all by current health systems, barriers may include socio-cultural factors, in addition to geography, education, poverty, etc.

For these families and others with inadequate health services, a truly equity-driven approach is needed. That is, governments, partners, health-providers, and systems will need find ways to provide whatever additional support is needed to help them catch up, not just make the same resources available to everyone.

For families, financial barriers to immunization are relatively low, but health and economic returns are high

The second indicator of the universal health coverage target acknowledges that the costs associated with health care – both preventative services and treatment for illness – are a significant barrier for hundreds of millions of people around the world. These costs prevent some people from even trying to access health services, and for those who do seek care they cannot afford, the financial burden of these services can have significant, negative and lasting economic impact. The provision of a basic package of preventative services, including immunization, would thus create a positive, reinforcing cycle of increased health-seeking behavior and improved financial stability for individuals, families and economies.

Immunization is a critical element to success for two reasons. First, thanks to global institutions such as Gavi and UNICEF, immunization is free of charge for a large proportion of families in the world’s middle and low-income nations and financial barriers to access are thus relatively low. However, not all crucial vaccines are yet available through national immunization programs in every country. In some places, lifesaving vaccines against disease such as pneumococcal disease are only available through the private market, carrying a price tag far too high for many families to access. And, as mentioned above, sociocultural factors and other issues are significant drivers of gaps in vaccine coverage and these must be addressed carefully and concertedly.

The second reason immunization is critical to meeting the financial risk protection targets of UHC is much more obvious: the widespread use of vaccines has the power to avert significant costs associated with treatment of infections. The huge economic burden of these infections stems from the costs associated with treating relatively low-cost but frequently occurring infections and complicated infections such as meningitis which are rare but very expensive to treat. These vaccine-preventable episodes of illness are responsible for a large number of families being pushed into poverty each year.

Visit the VoICE tool to find out more about how vaccines can help people avoid economic impoverishment from medical costs. Read our feature on medical impoverishment averted through immunization in 41 low-income nations.

A mother holding her child that is receiving a vaccine.

The hurdles that remain are high, but health for all awaits on the other side

The road to UHC will be fraught with risk and will require creative new ideas for reaching the unreached. For one, we must ensure that whatever systems are put in place to expand access to basic health interventions will not inadvertently damage immunization coverage, but will reinforce progress that has been made in expanding immunization coverage.

It is also clear that the achievement of UHC goals by 2030, or by any time, will require us to not only expand and improve upon the health systems that already exist, but also to change our approach to these imperfect health systems. Those families who receive no basic health services are called “hard to reach” for a reason. The challenge in devising a system flexible and comprehensive enough to reach everyone is very real, and very worthwhile.

The Unyielding Impact of Childhood Diarrhea


Despite tremendous global progress, diarrhea remains the second leading infectious cause of under-5 deaths, taking a child’s life almost every minute. Although diarrhea can seem like a common, simple childhood ailment in many places, a single episode of diarrhea can be serious, even deadly, and have severe economic implications for families and communities. Advocates play a critical role in ensuring evidence-based diarrhea prevention and control programs and policies are a top priority globally and in the countries where this disease is most prolific.

A selection of VoICE evidence in this issue

Chai, P.F., and Lee W. S. 2009. Out-of-pocket costs associated with rotavirus gastroenteritis requiring hospitalization in Malaysia. Vaccine. 27(5).

DeBoer, M.D., Chen, D., Burt, D.R. et al 2013. Early childhood diarrhea and cardiometabolic risk factors in adulthood: The Institute of Nutrition of Central America and Panama (INCAP) Nutritional Supplementation Longitudinal Study. Annals of Epidemiology. 23(6).

Loganathan, T., Lee, W.S., Lee, K.F., et al 2015. Household Catastrophic Healthcare Expenditure and Impoverishment Due to Rotavirus Gastroenteritis Requiring Hospitalization in Malaysia. PLOS One. 10(5).

Saha, S., Santosham, M., Hussain, M. et al. 2018. Rotavirus Vaccine will Improve Child Survival by More than Just Preventing Diarrhea: Evidence from Bangladesh. American Journal of Tropical Medicine and Hygiene. 98(2).

Riumallo-Herl, C., Chang, A.Y., Clark, S., et al. 2018. Poverty reduction and equity benefits of introducing or scaling up measles, rotavirus, and pneumococcal vaccines in low-income and middle-income countries: a modeling study. British Journal of Medicine Global Health. 3:e000612.

Burnett, E., Jonesteller, C. L., Tate, J. E., et al. 2017. Global impact of rotavirus vaccination on childhood hospitalizations and mortality from diarrhea.. The Journal of Infectious Diseases. 215(11).

Hendrix, N., Bar-Zeev, N., Atherly, D., et al 2017. The economic impact of childhood acute gastroenteritis on Malawian families and the healthcare system. BMJ open. 7(9).

Schlaudecker, E.P., Steinhoff, M.C. and Moore, S.R. 2011. Interactions of diarrhea, pneumonia, and malnutrition in childhood: recent evidence from developing countries. Current Opinion in Infectious Diseases. 24(5).

How preventing diarrhea can protect children, families, communities, and health systems

Despite tremendous global progress, diarrhea remains the second leading infectious cause of under-5 deaths, taking a child’s life almost every minute.[1],[2] Although diarrhea can seem like a common, simple childhood ailment, in many places a single episode of diarrhea can be serious, even deadly, and have severe economic implications for families and communities.

  • Repeated, prolonged diarrhea can have lasting – but sometimes overlooked – impacts on child health and development.
  • Treating diarrhea can be costly to families and health systems, and treatment costs can even push some families into poverty.
  • Rotavirus causes approximately one third of diarrhea deaths, and is only adequately preventable via vaccination – water, sanitation, and hygiene interventions that work to prevent other types of diarrhea don’t work to prevent rotavirus.
  • Cholera vaccination is used to stop endemic cholera and respond to cholera outbreaks, which are common in humanitarian emergency settings.

Advocates play a critical role in ensuring evidence-based diarrhea prevention and control programs and policies are a top priority globally and in the countries where the outcomes of diarrheal diseases are most devastating.

The burden of diarrhea globally

Each year, there are an estimated 1 billion episodes of diarrhea with approximately 500,000 deaths in children under five years of age.[1],[2] WHO estimates that children in low- and middle-income countries each have approximately three episodes of diarrhea a year.[3]  Although improvements have been made in our efforts to stop diarrhea deaths, we still have far too many episodes: since 1990, the number of diarrhea deaths has decreased by 65%, but the number of new diarrhea episodes has decreased by only 24%.[4] This burden is disproportionally concentrated in low- and middle-income countries, with over half of the diarrheal deaths occurring in sub-Saharan Africa – a low-resource setting where progress is slowest.[5]

The impact of diarrhea on children

Each episode of diarrhea deprives a child of nutrition necessary for growth and contributes to malnutrition, making these children more vulnerable to diarrhea yet less able to fight it.[3] After an episode of diarrhea, children grow less in length than children who did not have diarrhea.  When a child has repeated episodes of diarrhea, it can lead to chronic malnutrition and stunting, which in turn is associated with poor functional outcomes such as impaired cognitive development. Prolonged and frequent episodes of diarrhea in young children under the age of two affects them in later childhood and adolescence by leading to delays in school readiness and poor performance in school, as compared to their peers.

Episodes of diarrhea can exacerbate underlying undernutrition and can impair immunity hampering the ability to fight diseases such as pneumonia.[6] During diarrheal episodes, children can lose Vitamin A and zinc, which may predispose some children to pneumonia. In addition, children with more frequent episodes of diarrhea are more likely have chronic health issues later in life, like high blood pressure, which are taxing on both families and health systems.

Tools to defeat diarrhea

Aids to Help Protect and Prevent diarrhea disease and deaths

We have highly effective tools to fight diarrhea. Interventions to improve water, sanitation, and hygiene (WASH) have been successful in reducing the number of diarrhea cases.[7]  Exclusive breastfeeding for the first 6 months of life can protect infants from undernutrition and its associated vulnerability to diarrhea.[7] Inexpensive but effective treatments like oral rehydration salts (ORS) and zinc supplements work to stop diarrhea episodes from becoming severe and deadly. Yet, access to ORS and zinc is dismally low in many high-burden settings. In 6 of the 10 countries with the highest number of diarrhea deaths[7], national ORS coverage is below 40%.[8] In half of the 10 highest-burden countries[7], fewer than one in ten children have access to zinc supplements. In addition, we also see inequities in access to treatment. In at least half of the 10 highest-burden countries, ORS coverage was at least 10 percentage points lower in rural areas compared to urban areas, or in the poorest 20% of the population compared to the wealthiest 20%.[8]


Vaccination is our strongest protection against vaccine-preventable causes of diarrhea

Two types of common diarrhea are vaccine preventable: rotavirus and cholera. Rotavirus vaccines are especially crucial in preventing a large proportion of diarrhea deaths and hospitalizations around the world. Cholera vaccination is critical in preventing outbreaks in high-risk settings.

 Rotavirus vaccination can prevent hospitalizations and death

Although WASH interventions have successfully reduced the global burden of diarrhea, one main cause of diarrhea mortality – rotavirus – is not prevented through WASH interventions.[9],[10] Rotavirus is associated with approximately one third of diarrhea deaths and can only be adequately prevented through vaccination.[2],[9]

Rotavirus is a leading cause of diarrhea in infants.[5] This highly contagious virus kills about 200,000 children under 5 each year and is responsible for almost 40% of all diarrhea hospitalizations each year.[2],[5] Although ORS can treat simple cases of rotavirus, many of the world’s poorest children don’t have access to ORS.[8] Rotavirus vaccines have proven highly effective and impactful in countries where they have been introduced. In Malawi, for example, there was a 35% decrease in all-cause diarrhea deaths following rotavirus vaccination.[11] Rotavirus hospitalizations in children under 1 year fell by 80% after vaccine introduction.[12] As of January 2019, 97 countries have introduced rotavirus vaccines into their national schedule.[13] 

Current Rotavirus Vaccine Introduction Status*

Map of Current Rotavirus Vaccine Introduction Status
*As of January 2019

Rotavirus vaccination can protect health systems and resources 

Although diarrhea treatment is relatively inexpensive, when we factor in the sheer burden of diarrhea, these treatments are costly to health systems and require substantial health worker capacity.  Although many cases of diarrhea can be treated in outpatient facilities with low-cost treatment, inpatient treatment of diarrhea can cost hospitals 25 times the cost of outpatient treatment, per patient.[14]

Treating diarrhea uses limited health systems resources, such as hospital beds, and consequently consumes the resources that can be used to treat other diseases – often diseases aren’t preventable. Therefore, direct and indirect benefits of rotavirus vaccination programs play a critical role in reducing the strain on health systems. One in four children who were taken to a large pediatric hospital in Bangladesh were refused admission to the hospital because all of the beds were occupied. Acute diarrhea was one of the most common reasons for being admitted to the hospital, showing children with acute diarrhea filled many of the available hospital beds. Over half of the acute diarrhea cases that were admitted were due to rotavirus, showing that vaccination could prevent children from both needing and utilizing essential hospital resources.

We’ve seen tremendous reductions in hospitalizations for rotavirus diarrhea and all-cause diarrhea following rotavirus vaccine introductions.[15] A review of rotavirus vaccine introductions found that, globally, all-cause diarrhea hospitalizations reduced by almost 40% in children under 5 in regions where the vaccine had been introduced. The continued use and scale up of rotavirus vaccines will alleviate pressure from over-burdened facilities, enabling health systems to be more responsive.

Rotavirus vaccination may protect families from being pushed into poverty due to treatment costs

Rotavirus vaccination programs can protect the most vulnerable families from medical impoverishment and catastrophic healthcare costs. When looking at all-cause diarrhea In Malawi, the costs associated with treating diarrhea pushed families into poverty, with treatment costs exceeding the monthly income for one in six families needing inpatient care and one in ten families needing outpatient care. Families can be pushed into poverty by the costs of hospitalizing a child with rotavirus for several days. In Malaysia, the inpatient costs of rotavirus treatment can cost families 25% of an average family’s monthly income. Direct and indirect treatment costs, such as medicine and transportation, caused almost 9 in 10 Malaysian families to spend more than 10% of their monthly household income on treating rotavirus.

Rotavirus vaccine introduction in 41 GAVI-eligible countries could avert 40% of catastrophic health costs – 900,000 cases – and 40% of medical impoverishment – 200,000 cases. In other words, with rotavirus vaccination programs, 900,000 families would not incur health costs that are higher than a substantial proportion of their income and 200,000 families not would fall below the poverty line due to treatment costs. If rotavirus vaccination programs were introduced or scaled up in Gavi-supported countries, $200 million in out-of-pocket health expenses attributable to severe rotavirus infections could be averted, meaning low-income families would have more disposable income and greater financial stability. With vaccines being one of the more equitable health interventions accessible to poor families, they are an important strategy to reduce the gap in health outcomes by household income as well as protect many families from being pushed into poverty. Inequitable access to treatment, not an uncommon event, only exacerbates the disproportionate risk of mortality in vulnerable children, again underscoring the importance of preventing diarrhea in the first place and protecting children from the vicious aftermath of diarrhea.

Rotavirus vaccination can protect communities

Rotavirus vaccines provide immunity for not only children directly vaccinated but also affords protection to their families and communities. This herd immunity magnifies the public health benefit of rotavirus vaccination by extending protection to those age groups in the population who are not directly receiving the vaccine but can contract and transmit the disease. This additional benefit is essential for a resilient pathogen like rotavirus, that can live on surfaces – and therefore transmit disease – for days. As a result of rotavirus immunized children in the community, rotavirus hospital admissions in unvaccinated children aged two to five years of age, who were not age-eligible to receive the vaccine at the time, were reduced by 41% to 92% in hospitals across the US, showing the profound value of herd immunity.

Baby receiving vaccine

Cholera vaccination can protect vulnerable groups

Cholera burden

Diarrhea caused by cholera can be rapidly fatal, with as many as 1 in every 5 cases of cholera advances to severe disease.[16] Cholera, often called a disease of poverty, can be endemic and epidemic in settings without strong water and sanitation systems, such as humanitarian emergency settings. Because settings where cholera is most rampant are often those with weak or overburdened health systems, diagnosing and recording cases is difficult; the global estimates of cholera cases each year – between 1.3 and 4 million cases – likely underestimate the true burden.[16]

Unlike many vaccine-preventable diseases, the global number of cholera cases has been steadily climbing for the past 10 years. Devastating cholera epidemics have impacted Yemen, Haiti, Somalia, the Democratic Republic of Congo, and South Sudan in recent years, and continue to be a threat in fragile settings.[17] In addition to the health impacts of cholera, previous outbreaks have led to significant economic losses to countries, caused by reduced revenue on trade and tourism, and continue to threaten countries.[16]

Cholera vaccination

 Cholera vaccination is a crucial, cost-effective tool to fight cholera, especially in fragile settings that lack sufficient water and sanitation. In 2013, global partners collaborated to form a stockpile of the oral cholera vaccine, managed by the Global Task Force on Cholera Control and funded by Gavi, the Vaccine Alliance.[16] The stockpile has been utilized for mass vaccination campaigns for prevention in humanitarian crises and for reactive response to outbreaks.[17]

An important – and beneficial – feature of cholera is that vaccinating a relatively small number of people can result in significant herd protection. Research from Bangladesh suggests that 70% vaccine coverage can stop cholera transmission, which greatly amplifies the impact of vaccine campaigns and investments.[18] Cholera vaccination is also a critical tool in managing outbreaks and protecting national and global health security.

Continuing – and strengthening – the fight against diarrheal diseases

Certain types of serious diarrhea can be both preventable and treatable, and a large proportion of child diarrhea deaths can be prevented through vaccination. We have the tools to defeat diarrhea, but these tools are only effective when backed by strong political and financial commitment. The global fight against childhood diarrhea has undoubtedly had a profound impact on child health and broader societal development. Yet, consistently low treatment coverage and constraints in vaccine supply highlight ongoing challenges. These challenges must be responded to with the resources and commitment necessary to pick up the pace of progress, so we can be stronger in the global fight against one of the most common causes of childhood illness and death.

[1] WHO and Maternal and Child Epidemiology Estimation Group, Estimates of child cause of death, diarrhoea 2018. Retrieved from:

[2] Institute for Health Metrics and Evaluation (2018). Global burden of disease, GBD Results tool. Retrieved from:

[3] World Health Organization (2017).  Diarrheal Disease. Retrieved from:

[4] Troeger, C., Colombara, D. V., Rao, P. C., Khalil, I. A., Brown, A., Brewer, T. G., … & Petri, W. A. (2018). Global disability-adjusted life-year estimates of long-term health burden and undernutrition attributable to diarrhoeal diseases in children younger than 5 years. The Lancet Global Health, 6(3), e255-e269.

[5] Tate, J. E., Burton, A. H., Boschi-Pinto, C., Parashar, U. D., World Health Organization–Coordinated Global Rotavirus Surveillance Network, Agocs, M., … & Ranjan Wijesinghe, P. (2016). Global, regional, and national estimates of rotavirus mortality in children< 5 years of age, 2000–2013. Clinical Infectious Diseases62(suppl_2), S96-S105.

[6] Ibrahim, M. K., Zambruni, M., Melby, C. L., & Melby, P. C. (2017). Impact of childhood malnutrition on host defense and infection. Clinical microbiology reviews, 30(4), 919-971.

[7] WHO/UNICEF (2013). Ending preventable child deaths from pneumonia and diarrhoea by 2025: The integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD). Retreieved from:

[8] International Vaccine Access Center (IVAC), Johns Hopkins Bloomberg School of Public Health. (2018). Pneumonia and Diarrhea Progress Report 2018.

[9] Lamberti, L. M., Ashraf, S., Walker, C. L. F., & Black, R. E. (2016). A systematic review of the effect of rotavirus vaccination on diarrhea outcomes among children younger than 5 years. The Pediatric infectious disease journal, 35(9), 992-998.

[10] Glass, R. I., Parashar, U., Patel, M., Gentsch, J., & Jiang, B. (2014). Rotavirus vaccines: successes and challenges. Journal of infection, 68, S9-S18.

[11] Bar-Zeev, N., King, C., Phiri, T., Beard, J., Mvula, H., Crampin, A. C., … & Costello, A. (2018). Impact of monovalent rotavirus vaccine on diarrhoea-associated post-neonatal infant mortality in rural communities in Malawi: a population-based birth cohort study. The Lancet Global Health, 6(9), e1036-e1044.

[12] Burnett, E., Jonesteller, C. L., Tate, J. E., et al. 2017. Global impact of rotavirus vaccination on childhood hospitalizations and mortality from diarrhea.. The Journal of Infectious Diseases. 215(11), 1666-1672..

[13] International Vaccine Access Center (2018). VIEW-hub: Vaccine Introduction and Epidemiology Window. Retreived from: Accessed January 31, 2018.

[14] Sarker, A. R., Sultana, M., Mahumud, R. A., Ali, N., Huda, T. M., Haider, S., … & Morton, A. (2018). Economic costs of hospitalized diarrheal disease in Bangladesh: a societal perspective. Global health research and policy, 3(1), 1.

[15] Groome, M. J., Zell, E. R., Solomon, F., Nzenze, S., Parashar, U. D., Izu, A., & Madhi, S. A. (2016). Temporal association of rotavirus vaccine introduction and reduction in all-cause childhood diarrheal hospitalizations in South Africa. Clinical Infectious Diseases, 62(suppl_2), S188-S195.

[16] World Health Organization. (2017). Cholera vaccines: WHO position paper–August 2017. Weekly Epidemiological Record. 92(34), 477-498.

[17] Wierzba, T. F. (2018). Oral cholera vaccines and their impact on the global burden of disease. Human vaccines & immunotherapeutics, 1-8.

[18] Dimitrov, D. T., Troeger, C., Halloran, M. E., Longini, I. M., & Chao, D. L. (2014). Comparative effectiveness of different strategies of oral cholera vaccination in Bangladesh: a modeling study. PLoS neglected tropical diseases, 8(12), e3343.

Cancer and Immunization: More than meets the eye

Evidence from several disciplines indicates that immunization has a broader role to play in lessening the impact of cancer than one might expect. While it may be obvious that the widespread and growing use of vaccines against Hepatitis B and human papilloma virus (HPV) is directly responsible for preventing a significant number of related cancers, immunization against a host of other diseases may indirectly help to prevent additional cancers while helping to protect the health of immune-compromised cancer patients considerably. Read on for a brief explanation of how vaccines can prevent cancer, protect cancer patients and more.

The direct benefits of preventing cancer-causing infections

HepB and liver cancer

Introduced in 1982, the hepatitis B vaccine was the first widely available vaccine to directly prevent cancer. More than 1 billion doses of HepB vaccine have been delivered, resulting in a significant reduction in the chronic liver infection that leads to cirrhosis or cancer in roughly a quarter of adults. The risk of HepB infection begins at birth – and lasts throughout a person’s life – which is why HepB is the first vaccine most children receive, often within hours of coming in to the world. In fact, 80-90% of children who are infected with HepB during the first year of life will go on to develop chronic liver disease, dramatically increasing their cancer risk.

HPV and cancer

A leading cause of death among women, cervical cancer took the lives of more than a quarter of a million women in 2012, 85% of whom were from low- or middle-income countries. Cervical cancer is caused by human papillomavirus (HPV), a common infection that can lead to abnormal cell growth and high-mortality cancers. Just two of the more than 100 strains of HPV are responsible for 70% of cervical cancers and precancerous lesions. Each of the three available HPV vaccines has been proven effective in preventing infection with high-risk strains of HPV and could protect against other forms of cancer caused by the virus. The exceedingly high mortality rate for cervical cancer (1 in 2 women will succumb to the disease) is due largely to the lack of access to early detection and treatment for women in much of the world, and reinforces the urgency of prevention through vaccination.

Additional benefits

HepB, Hib and polio vaccines

Some intriguing new evidence suggests that vaccines against HepB, Hib and polio may indirectly help to prevent the development of childhood cancers. Some scientists have suggested that early and robust stimulation of a child’s immune system – such as that afforded by vaccination – could help the body recognize and neutralize early tumors, thus decreasing the risk of developing certain childhood cancers such as leukemia. A study from the state of Texas in the US tested this idea and found that children born in counties with high coverage of HepB, polio and Hib vaccine were 33-42% less likely to develop a specific kind of leukemia than children born in counties with low vaccine coverage. Although only a small number of studies have demonstrated this indirect benefit of immunization on childhood cancers thus far, it is an exciting new area we will be following closely.

Protecting cancer patients and survivors from other infections

Cancer and cancer treatments can severely diminish the body’s capacity to fight infection, putting cancer patients and survivors at significantly greater risk of vaccine-preventable diseases and death from secondary infections. For example, a study of adults in the US found that invasive pneumococcal disease was more than 20 times more likely to occur in cancer patients than in cancer-naïve people. In a large study that followed survivors of childhood and early adult cancers for more than 5 years, researchers found a significantly higher rate of infections than in the siblings of these patients. Cancer survivors in this study were also 4 times more likely to die of infectious causes than their siblings. Pneumonia, a potentially vaccine-preventable infection, carried some of the highest increased risk to cancer patients, even more than 5 years after cancer diagnosis.

Survivors of pediatric and young-adult cancers must also be concerned about developing other forms of cancer later in life, some of which may be preventable through use of the HPV vaccine. A large study in the US found that longterm cancer survivors – both men and women – appeared to have a significantly increased risk of developing HPV-associated cancers and malignancies later in life. For these reasons, it is critical that cancer patients and survivors be vaccinated, and sometimes re-vaccinated, to ensure the greatest possible protection from additional infection.

Herd immunity in the general population is also an important protective firewall for cancer patients [1] weakened by the disease who may not yet have been vaccinated. Immune-suppressive treatments commonly used to treat some forms of cancer may erase the immunity a patient had already built up through previous vaccination and leave the immune system too weak to tolerate immunization.

The economic benefits of cancer prevention are substantial

Preventing cancer has significant economic implications, and vaccines that help prevent cancer carry a significant return on investment in a variety of settings.

Hep B: Economic benefits

In terms of economic benefits, HepB vaccine carries a high economic return on investment, due in part to the sustained risk of infection across the lifespan. Health economists have estimated that during the decade 2011-2020, the use of this vaccine in the world’s poorest countries will have a return of over nine times its cost, thanks to the widespread use and high effectiveness of HepB Vaccine.

HPV: Health System and economic benefits

HPV vaccine is recommended to be given to girls in early adolescence (as opposed to most other childhood vaccines which are given during the first few years of life), which has resulted in some unique opportunities to expand delivery of other health services to this age group – even those not receiving the vaccine – and to form new collaborations between agencies that may help strengthen health programs overall.

Despite gradual uptake of HPV vaccine among the world’s poorest countries, health economists have estimated a 3-fold return on investment from the use of HPV vaccine in these countries during this decade (2011-2020). Averting the premature death of women through prevention of cervical and other HPV-related cancers increases overall productivity and would prevent destabilization of families and communities.

[1] High vaccine coverage in the general population significantly reduces the chance that an infectious agent is transmitted to others, significantly reducing the risk that an unvaccinated person will be exposed and infected. This phenomenon is called herd immunity.