Thank you Richard. It's a pleasure to be here with you. I recall listening from this morning, I did arrive a bit late from New York, but I've counted nine speakers so far who have given some type of an overview of the Global Immunization Program or what it does mean. So I will be as brief as I can going through to present a paper which was initially a joint paper for Dr. Joe Moukley, the WHO director of the Global Program on Vaccines and Immunization. If I might have my slides please, slide number 1. We've had a great deal of discussion today about the progress of immunization going from early 1980s, 1985 when most of the immunization coverage biantigen in the world was less than or approximately 20% with rise going up through to the year 1990 and following the intensive work in 1989, 1990 we have a slight decline in immunization coverage, although if one looks at the data one can see that the declines have been not significant and in 1993 and as 1994 data is coming in from countries we believe we have turned a corner to where by the end of 1995 we can approximate or even improve upon the 1990 performance. As we can see that the global averages for immunization really hide the disparities.
If we look at the immunization coverage from 1993 our most recent year of having complete data we can see that there is a great variation between the coverage in Africa in West and Central Africa are lowest region to that in South Asia and East Asia in the Pacific region and in the America's. What we see in Asia all countries with the exception of Papa New Guinea and Nepal, have maintained or improved on immunization coverage. In the America's region coverage has improved throughout the region since 1990. In the Middle East and North Africa, countries have continued to grow strong with the exception of Yemen, Algeria and some problems in Sudan. However, in Africa we find that the continent is at the bottom but again as we see among regions within the regions in Africa we have great variation as well. We have countries such as Tosenia Kenya, Malawi Uganda doing very well. Several of these countries much high than 70% coverage and some of them going up well above 80%. We have a whole set of small countries in Africa also doing very well. But again Africa, as been mentioned by two or three speakers today is a continent be set by civil strive have weak inter structure and has been having very serious economic constraints.
As we can see the second immunization goal for 1995 is that we achieve zero Polio levels in many countries. From this slide one can see that from 1985 through 1995 we have a continued increase in the number of countries which are reporting zero Polio. As one can see in 1988, much of the world still had circulating Polio. By 1992 we see the progress in the America's that the last case of Polio in the Western Hemisphere occurred in Peru in September of 1991. In September of 1994, the Robins commission certified that Polio had been eliminated in the Western Hemisphere. The other area of the world which has been making great progress since 1990 is the East Asia area or in WHO terms the Western Pacific region. With China, Vietnam, the Philippines followed by Cambodia making great strides reducing Polio. In the Middle East and Central Asia region, the last three months we had a very large immunization day with 23 countries participating together in National Immunization Day. With a population of under five's received Polio vaccines nearly as large as in China earlier in the year. Also we find that in Southern Africa there is a beach head of very low circulation of Polio virus and we have had discussions, fairly intensive discussions recently about how we can move ahead with Polio eradication throughout Sub-Saharan Africa. The challenge is as Dr. Foege mentioned this morning is one of getting adequate resources and getting adequate political commitment to finish the job in that we have a Polio champion in the Rotarians Rotary International has put together more than 300 million dollars to apply Polio eradication. We find that these resources are not adequate to complete the job by the year 2000 and as countries have to continue to immunize for Polio it was said by one of our colleagues a few months ago, it seems very strange that a country such as the United States would have to spend nearly a quarter of a billion dollars a year immunizing for a disease which they don't have. And by that we would encourage that the countries of the world who don't have Polio to try to help finish the job so that all can stop immunizing for Polio. The other major challenge is to adequate disease surveillance in diagnostic laboratory support which will be critical to being sure that we don't have Polio. As was mentioned by Dr. Nyi Nyi in an earlier presentation, approximately 84 countries should have reduced their measles incidence by 90%. We can see that the measles deaths has decreased dramatically if we are to achieve our year 2000 target or specifically the 1995 target of more than 90% reduction. We still have a ways to go. Several issues related to measles control have come up. One is that the America's region has embarked on the measles elimination following on the strategy of Polio eradication in that they have conducted national immunization days in nearly all of the countries of Latin America covering all children under the age of 15 and building on the Polio surveillance system whereby they have begun surveillance for fever and rash.
Measles remains a very difficult problem in Sub-Saharan Africa where it's highly virulent and frequently occurring in less than nine months of age with low coverage many of the countries in Africa have many communities which have less than 50% coverage. Transmission continues especially in urban areas. We're intensifying now a strategy which includes improving coverage generally added with special campaigns in urban areas and trying to improve disease surveillance.
Neonatal tetanus elimination has been defined as less than one case per thousand live births in every district of a country. Now more than 80 countries have reported reaching less than one per thousand live births many less countries can report less than one per thousand live births in every district. We find though epidemiologically neonatal tetanus occurring in countries occurs in clusters. We also find that most of the neonatal tetanus occurring in the world is centered in 12 countries in Asia and Africa. China, which had had a very important strategy they called the 'Three Cleans', this relates to the birthing process having the deliverer of the child have clean hands, a clean instrument for cutting the umbilical cord, and clean area for delivery should have eliminated neonatal tetanus. I have recent data from China to show that there are approximately a 100,000 cases. This shows us that immunization is a critical element in the elimination of neonatal tetanus. We find in many countries children who are born in a teaching hospital and stay two days or three days when they go home into an environment where they are cared for with traditional practices many children become infected even after the third or fourth day. Our approach for neonatal tetanus is to improve disease surveillance using a high risk approach. In Latin America they find that less than 10% of the districts throughout the continent of South America are considered high risk for neonatal tetanus and the strategy there is to reach all women of reproductive age with three doses of tetanus toxoid vaccine. Now if we apply this situation with China, the reproductive age of women is a very narrow age. The challenge there in China as in much of South Asia is to try to have the immunization programs work very closely with the maternal and child health programs, those who are responsible for anti-natal care. To reach these women and protect the children at birth.
One of the major challenges of the next several years is to assist developing countries to assure an adequate supply of high quality affordable vaccines. UNICEF and WHO together with UNDP the World Bank and Rockefeller Foundation had sponsored the children's vaccine initiative with several goals in mind. One is to bring new vaccines to bear into the immunization program. We are aware that we have Homoflous Influenza vaccine, we have Hepatitis B vaccine. There are several other vaccines which are waiting in the wings to fully incorporated into the immunization program. This is not happening very well. We've been more than a decade trying to get Hepatitis B in high risk countries into the immunization program. The excuses we get is that we don't have adequate resources and yet in the World Bank development report it is very clearly pointed out that immunization is one of the worlds most cost effective interventions. We would say perhaps we couldn't afford not to include them in the immunization program because the cost of immunizing children is much less than the cost of treating disease. Another challenge we have also is a major Diphtheria outbreak going on in Eastern Europe and Central Asia have more than 80 thousand cases of Diphtheria, in some countries a very high mortality rate. Again the issue which keeps coming up is where can we find the resources to deal with an outbreak like this. We in the immunization area wish that we could get the feeling of urgency, the feeling that something must be down and that perhaps we are not doing all we can as we have seen in the media most recently with the Ebola outbreaks in Zaire.
Again to summarize the immunization program as I noticed today tends to be the lode star or that program which many other programs are being compared to in terms of quality of data, in terms of maturity of strategies, and in terms of centrality in developing health care systems. We are very pleased with the progress since 1990 and the immunization program but again a great deal still needs to be done in order to achieve the potential and the promise that immunization programs offer for a maternal and child care. Thank you.