VWA has been a successful initiative for LAC countries to conduct supplementary immunization activities, target hard-to-reach groups, introduce new vaccines, and maintain immunization on the political agenda. Although the integration of other preventative interventions with VWA was never put forth as part of the framework of this initiative at the regional level, it has become clear that many LAC countries have chosen to take advantage of VWA as a platform for such activities.
Some countries have consistently integrated other preventative interventions with VWA, and others have done so more sporadically. It is likely that countries that regularly integrate interventions generally have closer coordination among health programs at the national level. Other factors that probably affect sustained integration include whether the yearly calendar of activities in both health programs coincides and whether the program to be integrated has consistent funding.
It has been discussed that linking another intervention to a strong immunization program has the possibility to quickly increase coverage and impact for the added intervention [14
]. For countries doing national VWA interventions and reporting coverage for both vaccination and integrated interventions, coverage seems to be high for both, and the targets are generally comparable. For example, during VWA 2009, Mexico reported national vaccination coverage ranging from 80.5% (Measles, Mumps, Rubella [MMR] vaccine dose to first-graders) to 107% (Diphtheria, Pertussis, Tetanus, Polio, Haemophilus Influenzae Type B vaccine [DaPT+IPV+Hib]) and coverage of both vitamin A supplementation and deworming treatment of 100%, based on their predefined target goals for each. In 2008, Nicaragua reported coverage ranging from 95% (Measles, Rubella [MR] vaccine) to 116% (Diphtheria, Hepatitis B, Haemophilus Influenzae Type B vaccine [DTP-HepB-Hib]) and coverage of vitamin A supplementation and deworming treatment at 96% and 90%, respectively.
In our review, however, routine coverage levels did not seem to be a determining factor as to whether an LAC country decided to integrate another intervention with immunization during VWA. Countries with routine coverage of >95% for several years, such as Mexico, have routinely integrated other health interventions during VWA. However, Haiti, the country with the lowest performance of all LAC countries, having never reached coverage of >70%, has integrated other services as well. It is not possible to assess the impact of the integration on vaccination coverage with the available data, but this is an important area for further investigation.
It should be noted that the integration of other health interventions with routine vaccination services has occurred in several LAC countries, predating the establishment of VWA. Belize, Bolivia, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, Peru, and perhaps other countries have historically integrated the delivery of vitamin A supplementation into their routine vaccine delivery, as well as in other annual campaigns [15
]. In Mexico, deworming efforts have been part of National Health Week since 1993; VWA occurs as part of the Second National Health Week in this country each year [16
]. Additionally, Argentina, Aruba, Bahamas, Barbados, Bermuda, Costa Rica, Cuba, Dominica, Dominican Republic, El Salvador, Grenada, Guyana, Mexico, the former Netherland Antilles, Nicaragua, Panama, Paraguay, Peru, St Kitts and Nevis, St Lucia, St Vincent and the Grenadines, and Trinidad and Tobago deliver a package of interventions, including immunization, as part of their school-based health programs, which are often integrated with oral health programs. Nevertheless, a recent systematic review on integration of immunization with other interventions in the developing world identified only 1 published article that presented data from Peru in a clinical trial integrating vitamin A supplementation into immunization services [14
]. Data from most of the integration activities in LAC countries are only available at the national level. The potential to further evaluate and document the lessons learned from LAC countries on the integration of other interventions with immunization is an important subject that remains to be explored.
Our article has several important limitations. First, we are using secondary data to explore the extent of integration of other interventions with vaccination as part of VWA. Although all participating countries are asked to annually report on a standardized list of items, including any integrated interventions that took place, the reporting of VWA results to PAHO varies widely by country in format, level of detail, and completeness. Thus, some integrated activities that took place may inadvertently be excluded from this analysis. Moreover, because vaccination has always been the primary focus of VWA, integrated interventions by countries are often described only superficially, without quantitative detail on coverage or other measures of impact. Such irregularities in data restrict the ability to compare data across countries and over time.
This review provides insight into the degree and type of integration that occurs during VWA in LAC countries and suggests that LAC countries are integrating other interventions with immunization to a much larger extent than was known internationally based on the peer-reviewed and gray literature. In 2010 and 2011, even more countries, particularly in the English-speaking Caribbean, integrated interventions during VWA efforts after informal encouragement by PAHO subregional offices. This summary of integration during VWA points to the need to promote better and more complete reporting of integrated activities and may serve as a baseline to plan for additional evaluations of integration practices in LAC.