Global Immunizations: Health Promotion and Disease Prevention Worldwide

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Janelle L. B. Macintosh Brigham Young University - Provo, [email protected]

Lacey M. Eden Brigham Young University - Provo

Karlen E. Luthy Brigham Young University - Provo

Aimee E. Schouten Brigham Young University - Provo

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BYU ScholarsArchive Citation Macintosh, Janelle L. B.; Eden, Lacey M.; Luthy, Karlen E.; and Schouten, Aimee E., "Global Immunizations: Health Promotion and Disease Prevention Worldwide" (2017). Faculty Publications. 5199. https://scholarsarchive.byu.edu/facpub/5199

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Health Promotion and Disease Prevention Worldwide and Disease Prevention Health Promotion Immunizations May/June 2017 diseases; about half of these deaths are young children and infants. Global travel is more common; diseases that were once loc Global travel is more common; deaths are young children and infants. half of these diseases; about around the world. now can be found in communities and trust in and perceptions of safety cost, Healthcare access, ed. have been identiﬁ Problem: Multiple barriers to immunizations have depressed global immunization rates. healthcare are factors that Interventions:as part of their efforts to increase immunization have focused on addressing these barriers Several global organizations Emergency Fund e and the United Nations Children’s Health Organization, World The Foundation, The Bill and Melinda Gates rates. that is concentrated on immunizations. have a part of their organization in Nurses can participate rates. can assist in increasing immunization Clinical Implications: Maternal child nurses worldwide can work with local and global Nurses immunizations. the burden of patients and families in accessing outreach programs to ease Nurses organizations to make immunizations more affordable. vital aspect of global which is a immunization rates, uence in the struggle to increase powerful inﬂ Nurses are a communities. promotion and disease prevention. Immunization. behavior; Key words: Barriers to immunizations; Global health; Health Abstract people in many areas of yet the most important health interventionsBackground: Immunizations are one of of the 20th century, worldwide die everyApproximately 3 million people year from vaccine-preventab adequate immunizations. the world do not receive Janelle L. B. Macintosh, PhD, RN, Lacey M. Eden, MS, NP-C, NP-C, MS, Eden, M. Lacey RN, PhD, Macintosh, B. Janelle L. Schouten E. and Aimee FAANP, FAAN, FNP, DNP, Luthy, Karlen E.

Downloaded from http://journals.lww.com/mcnjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/14/2021 Downloaded from http://journals.lww.com/mcnjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/14/2021 mmunizations are one of the most important health Misconceptions, misunderstandings, and misinformation interventions of the 20th century (Centers for Dis- have caused many to start refusing immunizations for ease Control and Prevention [CDC], 1999). In their children. Some believe that the diseases vaccines 2015, approximately 85% of children worldwide prevent are no longer a problem, at least in developed were vaccinated for tuberculosis, polio, diphthe- countries, or that vaccines do more harm than good ria, tetanus, pertussis, and measles (World Health (Luthy, Beckstrand, & Callister, 2010; Salmon et al., OrganizationI [WHO], & United Na- 2005; Wenger, McManus, Bower, & tions International Children’s Emer- Langkamp, 2011). Nurses can help gency Fund [UNICEF], 2016). Since overcome some barriers to immuni- 2010, nearly 235 million children zation such as access to healthcare, and young adults were vaccinated for cost, and perceptions of safety and meningitis A in the “meningitis belt,” trust. an area that covers 26 countries in sub-Saharan Africa (WHO Regional Photo Stock Alamy / BSIP SA Access to Healthcare Offi ce for Africa, 2016). Global im- Access to healthcare includes ability munizations are estimated to save 2.5 to make and keep appointments, million lives per year and are respon- ability to communicate with health- sible for the near eradication of polio care professionals, and availability of (CDC, 2016a; UNICEF, 2016a). Al- vaccines. Favin, Steinglass, Fields, though these statistics on global im- Banerjee, and Sawhney (2012) re- munization rates indicate signifi cant ported distance (travel conditions/ac- achievement, 3 million people still die cess), poor health staff motivation every year from vaccine-preventable and attitude (performance, knowl- diseases; approximately half of those edge, ability to communicate with deaths are young children and infants mothers), and lack of resources/logis- (WHO & UNICEF, 2016). tics (e.g., insuffi cient funding and Because worldwide travel is more stock that affect reliability, missed common, risk of spreading vaccine- opportunities to immunize and cold preventable diseases across the globe Immunizations chain [documentation of tempera- has increased. There are many rea- ture of vaccine from production to sons for world travel such as tour- save lives. delivery]) as common barriers to im- ism, visiting exchange students, munization and are found globally. adoption from foreign countries, Limited access to healthcare and life- work, and refugee assistance. Consequently, worldwide saving vaccines can be culturally grounded. For example, travel makes communicable diseases a more integrated China does not recognize migrants from North Korea as global problem. One recent example of the global legal citizens. Therefore, children of North Korean refugee migration of disease includes a measles outbreak that be- parents are deemed “stateless” in China and are not eligi- gan at Disneyland, California that spread measles to seven ble for medical care. Children born of North Korean other states in the United States, and the neighboring mothers and Chinese fathers are also not recognized as countries of Canada and Mexico in 2014. The origination legal citizens of China and are also not eligible for medical of the outbreak is unknown; however, “the measles virus care (Chung, Han, Kim, & Finkelstein, 2016). Because of type in this outbreak was identical to that recently found culturally based gender issues, a female in Israel may in the large measles outbreak in the Philippines” (CDC, encounter barriers to healthcare access (Schwartz et al., 2016b, para. 4). Worldwide immunization should be a 2013). focus of health promotion in all parts of the world. We Religious beliefs can also be a barrier to access to briefl y discuss selected barriers to immunizations, several healthcare, specifi cally immunizations. For example, organizations focused on overcoming these barriers, and trypsin is a component of oral polio vaccine and is ex- suggest ways nurses and medical professionals can imple- tracted from pork pancreas, which is prohibited in Islam. ment and be proactive agents of change. Therefore, in Islam dense regions, such as Pakistan, religious beliefs are a formidable barrier to receiving the po- Barriers lio vaccine (Khan et al., 2015). Current global immunization efforts reveal several barriers to immunizations based on culture and geographic Cost location. Obvious diffi culties that occur in developing Barriers to immunization also include cost. Cost in both countries include isolated locations and limited access to loss of time from work or household endeavors as well as healthcare, inadequate storage of vaccines, and insuffi - payment issues continue to plague people across the world cient funding (Delamonica, 2016; Prinja, Gupta, Singh, and limit immunizations. Poorer children are often not & Kumar, 2010). However, barriers present in highly de- adequately protected by herd immunity, as they are often veloped communities are just as, if not more, alarming. underimmunized and geographically clustered (Hossein-

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. poor et al., 2016). In a study of immunizations in 51 low- with medical personnel. Favin et al. (2012) in a study income and middle-income countries, large disparities evaluating why children are not vaccinated in various based on socioeconomic status were reported in and be- parts of the world including Africa, Asia, Latin America, tween countries (Hosseinpoor et al.). Immunization rates and the Middle East reported “unpleasant experiences within countries can be as much as a 72 percentage points with healthcare services (e.g., refusal of care, post vacci- different, whereas differences between countries can be as nation abscesses, verbal abuse or public humiliation)” much as 40 percentage points. This disparity is refl ected (p. 231) as considerable barriers. worldwide. Two studies revealed monetary cost as a barrier to Trust and Perception of Safety receiving immunizations in Asia. In Japan, medical Parents have immense infl uence in the immunization of students chose to not be immunized because it was too their children; therefore, it is imperative parents trust the expensive (Okamoto et al., 2008). In India, pediatricians information given by healthcare personnel (Luthy et al., most commonly reported cost as a barrier to recommend- 2010). Medical and nursing personnel must inform par- ing immunizations to their patients (Kahn, Thacker, ents that immunizations are not 100% risk free; however, Nimbalkar, & Santosham, 2014). immunizations are safe and risks are minimal. Unpleasant Mothers in Ethiopia felt that the costs associated with interactions with medical personnel may increase levels of immunizations were beyond monetary. McKnight and distrust, thus resulting in erroneous ideas about immuni- Holt (2014) found mothers felt overwhelmed with the re- zations and decreasing perceptions of safety. sponsibility to feed their families. The logistics of getting Accurate knowledge is paramount to increasing immu- their children immunized was not worth the time it took nization rates. Khan et al. (2015) reported that almost one away from the household (McKnight & Holt). Ethiopian third of participants, in Pakistan, feared infertility due to mothers felt getting their children vaccinated would be an the polio vaccine. Cultural myths and beliefs of locals in unpleasant demeaning task due to negative interactions Nigeria create barriers to immunizations (Babalola, 2011). Mistrust and erroneous ideas about immunization in Europe and North America have been compounded by the falsifi ed and Access to healthcare, cost, and perceptions of eventually retracted study linking the mea- safety and trust are barriers to immunizations. sles, mumps, rubella vaccine to autism (Wakefi eld et al., 1998; WHO, 2003). RGB Ventures/SuperStock/Alamy Stock Photo Stock Ventures/SuperStock/Alamy RGB

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Table 1. Vaccines, and the Global Vaccine Action Plan (GVAP) Accomplishments of Global Organizations (WHO, 2016a). The GVAP is a guide for achieving the goal of increas- The World Health Organization (WHO) ing vaccination coverage around the world. The primary • Creation of World Immunization Week 2016 slogan Close goal of GVAP is to prevent 25 million deaths by provid- the Immunization Gap ing access to immunizations for people of all communi- • 180 countries participated ties by 2020. Goals of at least 90% coverage in country • Vaccine-centered training and at least 80% in every district are set to be completed • Round tables by 2020. The vision of the GVAP is on all vaccine- • Informational campaigns preventable diseases; however, the ﬁ rst milestone is set • Vaccine distribution campaigns for polio eradication while encouraging research and • MenAfriVac program* development of the next generations of immunizations (WHO, 2016c). A secondary goal of GVAP is to increase • Custom vaccine developed for meningitis A quality of life and productivity in all nations. The push to • African male focus improve rates worldwide has increased. • 16 countries Although there are many organizations working to pre- • >237 million men and boys vent death from communicable diseases, not all organiza- • Ages 1–29 years tions will be discussed. We focus on three organizations that have the largest impact on global immunization rates. Bill and Melinda Gates Foundation The following organizations’ missions and strategies • Health equality for women and children are highlighted: 1) World Health Organization (WHO), • Focus on polio eradication 2) The Bill and Melinda Gates Foundation, and 3) United • Disease surveillance Nations International Children’s Emergency Fund (UNI- • Improve outbreak response CEF). Accomplishments of each organization are listed • Galvanize political support for immunizations in Table 1.

United Nations International Children’s The World Health Organization (WHO) Emergency Fund (UNICEF) Mission. The mission statement of the WHO is “to build a • Immunization campaigns better, healthier future for people all over the world. The • Reduced number of children’s deaths by half WHO ensures the safety of the air people breathe, the food they eat, the water they drink—and the medicines and vac- • 40% of world children immunized in 2014 cines they need” (WHO, 2016b, para. 1). Five of their six • Quadruple global childhood immunization rates leadership priorities involve immunizations: 1) enabling • >118 million women immunized for tetanus countries to sustain or expand access to all needed health • Thus providing immunization to newborns as well services, 2) addressing unfi nished and future challenges to • Reduce death from measles by 71% completing the eradication of polio, 3) ensuring that all • Polio eradication program* countries can detect and respond to acute public health • 0 cases of polio in Nigeria in 2015 threats (i.e., disease outbreaks), 4) increasing access to quality, safe, effi cacious, and affordable medical products * The Bill and Melinda Gates Foundation cosponsored program (i.e., vaccines), and 5) addressing the social, economic, and environmental determinants of health as a means to pro- Fear of side effects of immunizations is also a barrier mote health outcomes and reduce health inequalities linked to trust. Favin et al. (2012) reported that parents worldwide (WHO, 2016a). may refuse immunization for younger children after wit- Strategies. With offi ces in more than 150 countries, the nessing side effects in older children, or hearing about side WHO partners with the United Nations, public communi- effects in an acquaintance’s child. Increased trust with ties, countries, research institutes, and other organizations. medical and nursing personnel and accurate knowledge Members of the WHO seek to provide leadership on cru- can help dispel some of the misconceptions and break cial health problems and set the standards of good health. through barriers concerning safety of immunizations. The WHO is a major supporter and leader in the GVAP. Organizations Fighting to Increase The Bill and Melinda Gates Foundation Mission. The Bill and Melinda Gates Foundation aims to Immunization Rates “prevent more than 11 million deaths, 3.9 million dis- Global organizations have collaborated to reduce immu- abilities, and 264 million illnesses by 2020 through high, nization barriers and improve health worldwide. An over- equitable, and sustainable vaccine coverage and support arching goal of these organizations is to overcome multiple for polio eradication” (Gates Foundation, 2016, para. 1). barriers to immunizations in all countries so that all people, This foundation is also a major supporter and contributor especially children, have access to life-saving vaccines. In to the GVAP. Their goal is to save lives on an international 2012, the World Health Assembly endorsed the Decade of scale, especially children’s lives.

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Nurses are essential for increasing knowledge among community members about immunizations and helping them trust that immunizations are essential to promoting health and avoiding preventable diseases.

Strategies. The Bill and Melinda Gates Foundation un- on “[1] Expanding immunization coverage and vaccinat- derstands that global vaccination strategies are incredibly ing the hard to reach, [2] purchasing vaccines for more complex as there are unique struggles associated with each than a third of the world’s children, [3] improving the cold location, population, and cultural situation. Therefore, the chain to keep vaccines at a constant cool temperature, fi rst priority when working in any region is to partner with [4] engaging communities to explain the importance of locals to create a unique and specifi c plan. The foundation child vaccinations, [5] supporting the eradication of polio, contributes to development and innovation of vaccines [6] working towards a world without measles, rubella and from discovery to delivery, by investing in research to de- neonatal tetanus, and [7] introducing powerful new velop stronger vaccines, thereby lowering the amount of vaccines that disproportionately affect children in devel- antigen needed per dose and reducing the cost. Lowering oping countries” (UNICEF, 2016c, para. 4). the price of vaccine is an integral part of the battle to bring Strategies. As the world’s largest buyer of vaccines, immunizations to individuals globally. This foundation is UNICEF provides vaccines to 40% of the world’s chil- working with private industries to lower immunization dren (UNICEF, 2015). In 2011, to help drive down the costs as much as possible. They depend on systems within cost of vaccination, UNICEF began publishing the prices each country to ensure vaccines are safely and effectively they paid for each vaccine. The extensive outreach en- supplied and delivered to each individual. abled UNICEF members to negotiate the lowest price per vaccine possible. They also work with other partner The United Nations International Children’s organizations. Kiwanis International, an organization Emergency Fund centered on service, is one major partner. Together they Mission. The United Nations International Children’s provide more than 18 million volunteer hours every year Emergency Fund is dedicated to saving lives, building fu- and raise over $100 million annually. Rotary Inter- tures, and providing emergency relief, doing “whatever it national has joined UNICEF in the fi ght to eliminate takes to save and protect the world’s most vulnerable chil- polio worldwide since 1985. Rotarians span over 200 dren” (UNICEF, 2016b, para. 2). They have focused goals countries, providing critical backing to UNICEF in

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. vaccine delivery, transportation, and training healthcare seem out of reach for many, there are various ways nurses providers ( UNICEF, 2016d). can assist in overcoming barriers and increase vaccination rates worldwide. See Table 2. Barriers-Access. Improving access to immunizations in Promoting Immunizations by remote area of the world is paramount. Maternal child Overcoming Barriers nurses can participate in increasing availability of immu- By learning about a variety of organizations working to nizations by helping to increase the work force available bring vaccines to all people in all parts of the world, nurses to give immunizations. Maternal child nurses can become are better able to join forces and add their voices in the outreach nurses. Nurses can become educated on the pro- fi ght for global immunizations (see Table 2). As champi- cess of protecting vaccines through temperature regula- ons of health in their communities, maternal child nurses tion and then following those processes to bring vaccines around the world should become involved in this global to rural or underserved communities. Maternal child effort because what is being done abroad affects those at nurses can improve access by advocating for underimmu- home. Although making a difference worldwide might nized populations. Nurses can bring vaccines to people who are home bound or not allowed by culture to enter hospitals. Female nurses could take immunizations to Table 2. Nursing Actions to Overcome Barriers homes of mothers and children in places where women to Immunizations are not allowed to interact with male healthcare workers. Nurses can partner with Global Alliance for Vaccines and Access to Health Care Immunizations, WHO, and UNICEF and their local part- • Establish and participate in outreach programs ner to be the agent of change and improve immunization • Ensure temperature regulation protocols are followed rates in children and people of their community. when handling vaccines Barriers-Cost. Cost is closely linked to how available • Advocate for underimmunized populations immunizations are in many areas. Loss of valuable work • Partner with local and global organizations to improve time may be offset by nurses organizing vaccine cam- immunization rates in their community paigns where they work and help to immunize workers in • Bring immunizations to people and places that are not factories, fi elds, or offi ce buildings. The monetary costs allowed to interact with male healthcare personnel that often impeded immunizations may be offset by nurses (female nurses) working with Global Alliance for Vaccines and Immuni- zations, WHO, UNICEF, and the Bill and Melinda Gates Cost Foundation. Nurses can work with local healthcare offi cials • Organize campaigns to bring vaccine into work places to apply for grants to assist communities and individuals • Apply for grants and other funding to help offset cost of to pay for immunizations. Nurses can work with local immunizations for their community and global organizations to provide incentives for com- • Work with organizations to help provide incentives for munities who improve immunization rates. improvement in immunization rates Barriers-Perceptions. Nurses can contribute by joining forces and voices to increase community knowledge and Perceptions understanding of immunizations. Social media can be used • Use social media to help dispel misconceptions about to advocate for vaccines and dispel misconceptions. immunizations Maternal child nurses are essential to education. Women • Work with local women and mothers to instill trust and and mothers are vital to the acceptance and practice of resolve apprehension about immunizations health behaviors in communities around the world. Outreach campaigns that use local nurses to talk with community members and discuss the importance of immunizations are integral to instilling trust and resolve issues of apprehension in communities. Clinical Implications Vaccines are an important health discovery and have saved millions of lives. By protecting against disease, vaccines keep communities and children healthy. The world can be considered a smaller place than 20 years ago, as global travel is easier and more common than ever before. Vaccine-preventable diseases are more likely to affect a greater number of communities. Many barriers have been identifi ed that impede global immunization rates. Nurses are at the forefront in the fi ght against underimmunization. Nurses can improve

iStockphoto access to immunizations by participating in outreach

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. health surveys. The Lancet Global Health, 4(9), e617-e626. http:// dx.doi.org /10.1016 /S2214-109X(16)30141-3 Kahn, G. D., Thacker, D., Nimbalkar, S., & Santosham, M. (2014). High cost is the primary barrier reported by physicians who prescribe vaccines Maternal child nurses should not included in India’s Universal Immunization Program. Journal of Tropical Pediatrics, 60(4), 287-291. doi:10.1093/tropej/fmu012 be involved in local efforts to Khan, M. U., Ahmad, A., Aqeel, T., Salman, S., Ibrahim, Q., Idrees, J., & Khan, M. U. (2015). Knowledge, attitudes and perceptions towards improve immunization rates. polio immunization among residents of two highly affected regions of Pakistan. BMC Public Health, 15(1), 1. doi:10.1186/s12889-015-2471-1 Luthy, K. E., Beckstrand, R. L., & Callister, L. C. (2010). Parental hesitation in immunizing children in Utah. Public Health Nursing, 27(1), 25-31. doi:10.1111/j.1525-1446.2009.00823.x McKnight, J., & Holt, D. B. (2014). Designing the Expanded Programme programs that focus on underimmunized communities. on Immunisation (EPI) as a service: Prioritising patients over Maternal child nurses can improve immunization rates by administrative logic. Global Public Health, 9(10), 1152-1166. http:// dx.doi.org/10.1080/17441692.2014.972967 working with local and global organizations to ease the Okamoto, S., Slingsby, B. T., Nakayama, T., Nakamura, K., Fukuda, R., burden of receiving immunizations. Nurses also play a Gomi-Yano, H., …, Matsumura, T. (2008). Barriers to vaccination among Japanese medical students: Focus group interviews. Pediat- major role in educating and interacting with patients and rics International, 50(3), 300-305. doi:10.1111/j.1442-200X.2008.02576.x can improve understanding in their own communities. Prinja, S., Gupta, M., Singh, A., & Kumar, R. (2010). Effectiveness of plan- Maternal child nurses must answer the call to fi ght against ning and management interventions for improving age-appropriate immunization in rural India. Bulletin of the World Health Organization, the low immunization rates, and thereby improve health 88(2), 97-103. doi:10.2471/BLT.08.059543 around the world. ✜ Salmon, D. A., Moulton, L. H., Omer, S. B., DeHart, M. P., Stokley, S., & Halsey, N. A. (2005). Factors associated with refusal of childhood vaccines among parents of school-aged children: A case-control study. Archives Janelle L. B. Macintosh is an Assistant Professor at Brigham of Pediatrics and Adolescent Medicine, 159(5), 470-476. doi:10.1001/ Young University College of Nursing, Provo, UT. The author archpedi.159.5.470 Schwartz, A. W., Clarfi eld, A. M., Doucette, J. T., Valinsky, L., Karpati, can be reached via e-mail at [email protected] T., Landrigan, P. J., & Sternberg, S. A. (2013). Disparities in pneu- Lacey M. Eden is an Assistant Professor at Brigham mococcal and infl uenza immunization among older adults in Young University College of Nursing, Provo, UT. Israel: A cross-sectional analysis of socio-demographic barriers to vaccination. Preventive Medicine, 56(5), 337-340. doi:10.1016/j. Karlen E. Luthy is an Associate Professor at Brigham ypmed.2013.01.019 Young University College of Nursing, Provo, UT. United Nations International Children’s Emergency Fund. (2015, Aimee E. Schouten is a BSN student at Brigham Young November). World Immunization Week 2015, Facts and fi gures, Nov 2015 update. Retrieved from www.unicef.org/immunization/fi les/ University College of Nursing, Provo, UT. Immunization_Facts_and_Figures_Nov_2015_update.pdf United Nations International Children’s Emergency Fund. (2016a). Immu- nization, Polio. Retrieved from https://www.unicefusa.org /mission/ There are no potential confl icts of interest, real or survival /immunization/polio perceived. United Nations International Children’s Emergency Fund. (2016b). Our mission. Retrieved from https://www.unicefusa.org/mission Copyright © 2017 Wolters Kluwer Health, Inc. All rights United Nations International Children’s Emergency Fund. (2016c). reserved. Immunization, The big picture. Retrieved from www.unicef.org/ immunization /index _bigpicture.html DOI:10.1097/NMC.0000000000000337 United Nations International Children’s Emergency Fund. (2016d). Immunization, UNICEF’s immunization partners, Working together to save lives. Retrieved from https://www.unicefusa.org/mission/ References survival/immunization /partners Babalola, S. (2011). Maternal reasons for non-immunisation and partial Wakefi eld, A. J., Murch, S. H., Anthony, A., Linnell, J., Casson, D. M., immunisation in northern Nigeria. Journal of Pediatrics and Child Malik, M., …, Walker-Smith, J. A. (1998). RETRACTED: Ileal-lymphoid- Health, 47(5), 276-281. doi:10.1111/j.1440-1754.2010.01956.x nodular hyperplasia, non-specifi c colitis, and pervasive developmental Bill and Melinda Gates Foundation. (2016). What we do-Vaccine delivery. disorder in children. Lancet, 351(9103), 637-641. http://dx.doi.org/10.1016 Strategy overview. Retrieved from www.gatesfoundation.org/What- /S0140-6736(97)11096-0 We-Do/Global-Development/Vaccine-Delivery Wenger, O. K., McManus, M. D., Bower, J. R., & Langkamp, D. L. (2011). Centers for Disease Control and Prevention. (1999). Impact of vaccines Underimmunization in Ohio’s Amish: Parental fears are a greater universally recommended for children—United States, 1990-1998. obstacle than access to care. Pediatrics, 128(1), 2009-2599. doi:10.1542/ Morbidity and Mortality Weekly Report, 48(12), 243-248. Retrieved peds.2009-2599 from www.cdc.gov/mmwr/preview/mmwrhtml/00056803.htm World Health Organization. (2003). Global vaccine safety. Weekly Epidemiologic Record. 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