WHO Vaccination Schedules and Updates
Users may want to determine whether a child received the recommended vaccinations at the recommended times. This requires knowledge of the recommended vaccination schedule in place at a given country at a specific time, the child’s age, and the date of the vaccination. This user note describes the changes in recommended vaccination schedules across time and across all countries included in IPUMS-DHS.
The Expanded Program on Immunization
In May 1974, the World Health Organization (WHO) created the Expanded Program on Immunization (EPI) to increase vaccine coverage among children throughout the world. The success of the smallpox eradication program, based largely on an international vaccination campaign, prompted WHO to implement similar campaigns to eradicate other diseases. The EPI regularly releases vaccination guidelines, and national governments create and implement policies based on these recommendations. Because vaccination schedules are determined by national governments, the schedules may vary between countries. By the early 1980s, all United Nations member states had created their own national EPI.
In 1999, the Global Alliance for Vaccines and Immunization (GAVI) was created to increase access to immunization and to improve child health in the poorest countries. GAVI is a global health partnership of UN agencies (including WHO, UNICEF, and the World Bank Group), public health institutions, governments of both donor and implementing countries, non-governmental organizations, the vaccine industry, the Bill and Melinda Gates Foundation, the Rockefeller Foundation, and many other public and private institutions. GAVI provides expertise and financial support to make vaccines more affordable and available in poorer countries. When new vaccines are less cost-prohibitive, it becomes easier for the national EPI to add these new vaccines to the schedule.
Recommended Vaccination Schedule
In 1984, the EPI created the first standardized vaccination schedule. In this first incarnation, the schedule recommended the following four vaccines against six diseases:
- Tuberculosis (BCG) - at birth
- Diphtheria, tetanus, and pertussis (DPT vaccine) - 6, 10, and 14 weeks
- Measles - 9 months
- Poliomyelitis - 6, 10, and 14 weeks
In the years since the creation of this first schedule, there have been several changes and additions to the vaccine recommendations, based on scientific advancement in vaccine creation and changes in the characteristics and prevalence of diseases worldwide.
Below is a list of vaccines that were added to the recommended schedule, or for which the recommendation has changed significantly over the years:
- In 1988, a yellow fever vaccine was introduced to countries in which yellow fever is endemic.1 This vaccine is frequently given at the same time as the measles vaccine. According to WHO, a single dose of the yellow fever vaccine is sufficient for protective immunity against the yellow fever disease; a booster dose is not required.
- In 1992, a vaccine against hepatitis B was added to the schedule, and by 1997, it was recommended as a vaccine in all countries. GAVI has financially supported the 3-dose primary series of this vaccine since 2000 (excluding birth dose), which has allowed even the poorest countries to incorporate it into their immunization schedules. WHO recommends that all infants receive the hepatitis B vaccine as soon as possible after birth, which should be followed by 2 or 3 doses to complete the primary series. Many countries have not incorporated the birth dose of the hepatitis B vaccine into their national schedules, as a high proportion of births occur outside a health facility, making it difficult to reach newborns in time. The 3-dose primary series is often given at the same time as the DPT vaccine. No booster vaccinations are recommended for individuals who have completed the 3 dose vaccination schedule.
- In 1998, the Haemophilus influenzae type b vaccine was added to the recommended vaccination schedule for certain high-risk countries, and in 2006, it was added to the recommended schedule for all countries. The vaccine works against Haemophilus influenzae, which causes bactermia, pneumonia, epiglottis, acute bacterial meningitis, and sometimes cellulitis, ostemyelitis, and infectious arthritis. In general, a 3-dose primary series is recommended, beginning at 6 weeks of age. The series is often given at the same time as the DPT vaccine. When the Haemophilus influenzae type b vaccine is administered with the DPT and hepatitis B vaccines, this is known as the pentavalent vaccine.
- The measles vaccine has been included in the EPI since its foundation, but the type and number of recommended vaccinations has changed. Originally, the vaccine was a single dose against measles only, administered at 9 months as an injection in the child’s upper arm. As new vaccines have been added to the recommended schedule, it was determined that some may be administered at the same time as the measles vaccine. Most commonly, these include the vaccines for mumps and rubella. Beginning in 2000, the World Health Organization recommended the rubella vaccine in countries with high child immunization rates where congenital rubella syndrome (CRS) is considered a public health priority. In 2011, WHO recommended that all countries with measles vaccine coverage above 80% introduce the rubella vaccine. The measles and rubella vaccine (MR), or any rubella-containing vaccine (RCV) is more than 95% effective against rubella after only 1 dose. It is recommended that countries achieve and maintain immunization coverage (1 dose of RCV) of at least 80% to avoid the potential risk of an increase in CRS.
- In 2001, WHO recommended the introduction of the mumps vaccine, to be administered with the vaccines for measles and rubella (MMR). The mumps vaccine is only recommended for countries with strong measles immunization programs - only countries with sustained vaccine coverage above 80% for measles and rubella should introduce the mumps vaccine to their immunization schedule. For both mumps and rubella, insufficient childhood vaccination coverage against mumps or rubella can result in higher rates of disease incidence in older age groups.
- In 2009, WHO began recommending two doses of the measles, or any measles containing vaccine (MCV). Depending on the vaccination schedule in a specific country, the two-dose series may consist of a combination of one or two doses of the measles vaccine, the measles and rubella vaccine, or the measles, mumps, and rubella vaccine. The second dose of a measles-containing vaccine should be administered between 15 and 18 months.
- There are two main types of polio vaccines: the oral polio vaccine (OPV) and the inactivated polio vaccine (IPV). OPV, which was included in the original EPI vaccination schedules, contains attenuated (weakened) polioviruses, which enable vaccinated individuals to become immune to the virus. Almost every country that has eradicated polio used OPV to stop person-to-person transmission of the virus. OPV is safe, easy to administer, and effective, but in extremely rare cases, the live attenuated vaccine-virus found in OPV can cause paralysis in the vaccinated child (vaccine-associated paralytic poliomyelitis, or VAPP). VAPP cannot be transmitted to other individuals. Another very rare outcome is circulating vaccine-derived poliovirus (cVDPV), a genetically altered strain of the attenuated virus that can cause paralysis and infect other individuals with the poliovirus. This can become a problem in communities with insufficient vaccination coverage.
- Although the risk of VAPP and cVDPV are both very low, many countries that have eradicated polio are switching to IPV, which is administered as an injection. The World Health Organization first recommended this switch in 2003. IPV does not contain a live virus, and so there is no risk of VAPP. IPV causes individual to become immune, but because of the low level of intestinal immunity, when someone immunized with IPV becomes infected with wild poliovirus, the virus can still grow inside the intestine and be transmitted to other individuals through the child’s feces. As a result, only polio-free countries are switching from OPV to IPV, when the risk of paralytic polio associated with OPV is determined to be greater than the risk of the wild polio virus spreading through individuals vaccinated with IPV. When polio (wild polio) has been completely eradicated, the use of OPV will need to be stopped to prevent VDPVs from returning.
- In 2006, the rotavirus vaccine was added to the recommended vaccination schedules in North America, Latin America, and Europe, and in June 2009, it was added to the recommended schedule for all countries. Rotavirus is the most common cause of severe diarrheal disease in young children around the world. The vaccine is given orally, with the first dose given at 6 weeks of age.
- In 2006, the World Health Organization recommended a vaccine against Japanese encephalitis in all regions where the disease is a recognized public health problem. Japanese encephalitis is the main cause of viral encephalitis in many countries of Asia, including India, Bangladesh, Nepal, and Pakistan. The disease is found primarily in rural and periurban areas, and humans can become infected when bitten by an infected mosquito. Because the vaccine, which is administered as an injection, does not induce herd immunity, high rates of vaccination coverage should be achieved and maintained in regions at risk of the disease. India introduced the vaccine in 112 districts from 2006 to 2010, and since then, it has been added to the vaccination schedule nationwide.
- In 2007, the World Health Organization added the pneumococcal conjugate vaccine (PCV) to its recommended vaccination schedule in all countries. Diseases caused by Streptococcus pneumoniae (pneumococcus) include pneumonia, meningitis, febrile bacteraemia, otitis media, sinusitis, and bronchitis. In developing countries, the disease is most common in newborn infants and children under age 2. The vaccines, which are administered as injections, are designed to protect against the serotypes that are most commonly associated with severe pneumococcal diseases.
For more information about recommended vaccinations, users may wish to review the WHO position papers. In 1999, the Strategic Advisory Group of Experts on Immunization (SAGE) was established to guide vaccination recommendations. SAGE meets twice a year to review information related to immunization and vaccine-related topics and to modify recommendations which are then reflected in the WHO vaccine position papers.
Below you can find links to position papers for vaccines relevant to the Demographic and Health Surveys:
|Haemophilus influenzae type b||2013, 2006, 1998|
|Hepatitis B||2009, 2004|
|Japanese encephalitis||2015, 2006, 1998|
|Pertussis||2015, 2010, 2005, 1999|
|Pneumococcal||2012, 2007, 2003|
|Polio||2016, 2014, 2010, 2006, 2003|
|Rotavirus||2013, 2009, 2007, 2003, 1999|
|Yellow fever||2013, 2003|
For more information about the most recent WHO recommendations, see the "Summary of WHO Position Paper - Recommended Routine Immunizations for Children (updated September 2016)."
Country-Specific Vaccination Schedules
Because each country sets its own standards based on the Expanded Program on Immunization, we recommend users learn more about the vaccine schedules in place in the country of interest during the 3 to 5 years before the survey. The following chart indicates the year in which each country included in IPUMS-DHS introduced the given vaccine throughout the country. Users should be aware that countries often implemented a vaccine in one region of the country before expanding the coverage to the entire nation.
*The addition of a second-dose of a measles-containing vaccine may be the same as the addition of the measles and rubella vaccine. Users should consult the resources listed below for more information.
**Zimbabwe removed the hepatitis B vaccine from the routine immunization schedule due to insufficient funding. The vaccine was permanently added to the schedule in 1999.
For more information about a specific country’s immunization plan, we also recommend the following sources:
- The Final Reports, published with each Demographic and Health Survey, indicate which vaccines are included in their vaccination schedule, as well as the recommended timing for each vaccine. They also provide information on what it means for a child to be considered completely vaccinated at that country at that time.
- The World Health Organization’s page on Data, statistics, and graphics for Immunization, Vaccines and Biologicals. This page contains links to immunization schedules by vaccine, year of introduction of vaccines by country (including partial or regional introduction), disease incidence, and regional summaries.
- The Country Planning Cycle Database, a World Health Organization resource, includes recent documents related to all areas of health goals. We suggest looking in the “County Documents” section of the country of interest. Comprehensive multi-year plans and documents about the Expanded Program on Immunization may be the most helpful.
- The Global Alliance for Vaccines and Immunizations provides information on vaccination in GAVI-eligible countries. We suggest users select their country of interest, and then “Country Documents.” The category “Comprehensive multi-year plans” may be the most useful.
1. Countries with risk of yellow fever virus (YFV) transmission: Angola, Argentina, Benin, Bolivia, Brazil, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Colombia, Republic of the Congo, Cote d'Ivoire, Democratic Republic of the Congo, Ecuador, Equatorial Guinea, Ethiopia, French Guiana, Gabon, The Gambia, Ghana, Guinea, Guinea-Bissau, Guyana, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Panama, Paraguay, Peru, Senegal, Sierra Leone, South Sudan, Sudan, Suriname, Togo, Trinidad and Tobago, Uganda, Venezuela (CDC, January 4, 2017)