**2.6 Challenges of measles immunization in resource-limited settings**

Vaccination history of children is not documented in hospital's records because many people do not properly keep children's/wards' vaccination records. This is coupled with high illiteracy level found in many developing countries [32]. Many people present as emergencies upon admission, at which point their parents cared less about vaccination status because they were overwhelmed by anxiety. There is need for enhanced comprehensive national vaccination campaigns with intense community engagement and diligent health workers including large number of ad-hoc staff. Weak government support across all levels is responsible for poor surveillance activities hence, their inability to detect new cases. Awareness creation should be intensified to inform concerned citizens about the essence and time of vaccination.

Ability to produce vaccines is a major setback for developing countries. Japan International Cooperation Agency (JICA) is currently supporting transfer of a Measles-Rubella vaccine manufacturing technology to Polyvac® in Vietnam, following the precedent set by multiple previous successful projects. Transfer of an oral polio vaccine (OPV) technology from Biken Co., Ltd. to Bio Farma in Indonesia was pivotal in the global polio eradication efforts. JICA supports UNICEF supply of vaccine cold chain equipment to India, Afghanistan, Angola, Liberia, Zambia and Zimbabwe which has significantly overcome the problem of vaccine failure resulting from inability of most immunization officers to maintain cold chain in remote areas.

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**2.7 Sourcing of vaccines**

*Measles in Developing Countries*

*DOI: http://dx.doi.org/10.5772/intechopen.84188*

Government bodies responsible for ensuring safety and effectiveness of vaccines face serious challenges when protecting the public from harm once the products are used in uncontrolled, real world context [39–41]. Regulations have been moving towards an approach that takes into account the full lifecycle of the vaccine. While this shift has been very slow in countries like Canada, there have been further calls for changes on how regulators safeguard public health and public healthcare resources [42]. This approaches are a far cry from the reality on ground in developing countries, because they utilize whatever vaccines are supplied by donor agencies

or vendors who have passed through government's registration processes.

who are biased against vaccines in light spurious or religious sentiments.

Masking of geographical inequalities in vaccination because of poor administrative summaries is a big problem. Spatial clustering of unvaccinated children sustains disease transmission, even when high overall vaccination coverage is achieved. Continued measles virus circulation occurs as a result of missing age cohorts during routine vaccination. Access to high quality vaccines is important however, there is limited expertise to review technical product information in vaccine regulatory dossiers hence the inability to effectively register and supply vaccines in many developing countries. They lack appropriate expertise and certified personnel to perform good manufacturing practice (GMP) inspections leading to lengthy registration/ review process and delays in vaccine registration even in emergency situations. Worrisome is the fact that there is limited compliance with good clinical practice standards for some clinical trials. Therefore, improving vaccine supply chain in developing countries is very important. A review of existing data shows freeze exposure occurred in 18–67% of vaccine shipments throughout various stages of storage. Also, heat denatures vaccines when cold chain is not maintained. Such may reduce vaccine potency, ultimately supplying potentially less-effective vaccines.

The developing countries vaccine manufacturers' network (DCVMN) is a public

health driven, international alliance of manufacturers trying to strengthen vaccine supply through information and professional training programs, technology improvements, innovative vaccine research and development, encouraging transfer initiatives, to improve availability of safe, effective and affordable vaccines. Three goals were proposed for vaccines. First, to ensure uninterrupted supply of affordable and suitable vaccines for GAVI. Second, improve market dynamics information and expertise to solve vaccine access challenges. Third, strengthening global health and manufacturers' partnerships to enable better alignment of goals, alignment

with global strategy and coordination of internal investments [43].

Most countries grapple with unreliable immunization service funding. But in spite of active measles vaccination efforts in several developing countries, reemergence of measles continues to occur [33]. An interplay of several factors affect immunization. These factors include break in cold-chain of measles vaccine due to long distance to vaccination centers, history of measles, intercurrent infections and malnutrition. In both developing and industrialized countries, loss of public confidence in vaccine due to real or spurious links to adverse events can curtail or even halt immunization activities. This is similar to reports about polio vaccine laced with sterilizing agents which led to decline in vaccination uptake in northern Nigeria. Despite the scientific evidence refuting links between the measles-mumpsrubella (MMR) vaccine and autism, there has been decline in coverage in some countries as a result of this. Measles is making a comeback in several industrialized countries, including Austria, Italy and the United Kingdom. This can be attributed to presence of migrants and refugees from developing countries especially those

#### *Measles in Developing Countries DOI: http://dx.doi.org/10.5772/intechopen.84188*

*Viruses and Viral Infections in Developing Countries*

**2.5 Measles vaccination coverage in Africa**

developing countries. Nigeria is the most populous country in Africa with a population of over 160million. In an assessment of immune status carried out in 2014, herd immunity against measles was 66.8% in Kano State and 73.0% in Ibadan, Oyo State. These are two largely different populations in the north and southern respectively [33]. When history of measles was compared with level of immunity, a significant association was observed between those who had measles and who had protective immunity. There was strong correlation between malnutrition and immune level, a

lot of malnourished children who were vaccinated were not protected [33].

maries may still mask important geographical inequities in coverage [38].

**2.6 Challenges of measles immunization in resource-limited settings**

Vaccination history of children is not documented in hospital's records because many people do not properly keep children's/wards' vaccination records. This is coupled with high illiteracy level found in many developing countries [32]. Many people present as emergencies upon admission, at which point their parents cared less about vaccination status because they were overwhelmed by anxiety. There is need for enhanced comprehensive national vaccination campaigns with intense community engagement and diligent health workers including large number of ad-hoc staff. Weak government support across all levels is responsible for poor surveillance activities hence, their inability to detect new cases. Awareness creation should be intensified to inform concerned citizens about the essence and time of vaccination. Ability to produce vaccines is a major setback for developing countries. Japan International Cooperation Agency (JICA) is currently supporting transfer of a Measles-Rubella vaccine manufacturing technology to Polyvac® in Vietnam, following the precedent set by multiple previous successful projects. Transfer of an oral polio vaccine (OPV) technology from Biken Co., Ltd. to Bio Farma in Indonesia was pivotal in the global polio eradication efforts. JICA supports UNICEF supply of vaccine cold chain equipment to India, Afghanistan, Angola, Liberia, Zambia and Zimbabwe which has significantly overcome the problem of vaccine failure resulting from inability of most immunization officers to maintain

Strategies based on vaccination program have been implemented in order to reduce measles mortality. In 2008, countries in the WHO African Region adopted measles pre-elimination goal to be achieved by the end of 2012. Target was to achieve >98% reduction in estimated regional measles mortality. The goal was to have national measles incidence of <5 cases per 1,000,000 population per year, achieve >90% national coverage with MCV1 with >80% MCV1 coverage target. For SIAs, MCV coverage >95% was targeted in all districts [16]. In the WHO regions, highest percentage of reduction was in Eastern Mediterranean (90%) and African (89%) regions, accounting for 16 and 63% of global reduction [34, 35]. Relatively high measles vaccination in southern Nigeria in West Africa can be attributed to high level of literacy and awareness created by free use of mass media to disseminate information on vaccination activities, without fear of intimidation [33]. The Global Vaccine Action Plan (GVAP) set out a target of reaching 80% coverage with all vaccines including measles vaccine in all districts by 2020 [36]. Health policy decision-making based on spatially heterogeneous vaccination has resulted in shift from pursuing coverage targets at national-level to ensuring high coverage levels evenly distributed across provinces or districts [37]. While this likely represents a more effective strategy over targeting country-level goals, administrative area sum-

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cold chain in remote areas.

Government bodies responsible for ensuring safety and effectiveness of vaccines face serious challenges when protecting the public from harm once the products are used in uncontrolled, real world context [39–41]. Regulations have been moving towards an approach that takes into account the full lifecycle of the vaccine. While this shift has been very slow in countries like Canada, there have been further calls for changes on how regulators safeguard public health and public healthcare resources [42]. This approaches are a far cry from the reality on ground in developing countries, because they utilize whatever vaccines are supplied by donor agencies or vendors who have passed through government's registration processes.

Most countries grapple with unreliable immunization service funding. But in spite of active measles vaccination efforts in several developing countries, reemergence of measles continues to occur [33]. An interplay of several factors affect immunization. These factors include break in cold-chain of measles vaccine due to long distance to vaccination centers, history of measles, intercurrent infections and malnutrition. In both developing and industrialized countries, loss of public confidence in vaccine due to real or spurious links to adverse events can curtail or even halt immunization activities. This is similar to reports about polio vaccine laced with sterilizing agents which led to decline in vaccination uptake in northern Nigeria. Despite the scientific evidence refuting links between the measles-mumpsrubella (MMR) vaccine and autism, there has been decline in coverage in some countries as a result of this. Measles is making a comeback in several industrialized countries, including Austria, Italy and the United Kingdom. This can be attributed to presence of migrants and refugees from developing countries especially those who are biased against vaccines in light spurious or religious sentiments.

Masking of geographical inequalities in vaccination because of poor administrative summaries is a big problem. Spatial clustering of unvaccinated children sustains disease transmission, even when high overall vaccination coverage is achieved. Continued measles virus circulation occurs as a result of missing age cohorts during routine vaccination. Access to high quality vaccines is important however, there is limited expertise to review technical product information in vaccine regulatory dossiers hence the inability to effectively register and supply vaccines in many developing countries. They lack appropriate expertise and certified personnel to perform good manufacturing practice (GMP) inspections leading to lengthy registration/ review process and delays in vaccine registration even in emergency situations. Worrisome is the fact that there is limited compliance with good clinical practice standards for some clinical trials. Therefore, improving vaccine supply chain in developing countries is very important. A review of existing data shows freeze exposure occurred in 18–67% of vaccine shipments throughout various stages of storage. Also, heat denatures vaccines when cold chain is not maintained. Such may reduce vaccine potency, ultimately supplying potentially less-effective vaccines.
