Afghanistan has a population of over 28 million people with high rates of poverty, illiteracy, and lack of access to basic services like water and healthcare. Rates of childhood diseases and mortality are extremely high. The country's immunization program aims to increase vaccine coverage and reduce disease incidence, but faces major challenges including insecurity, lack of access to vulnerable populations, and underfunding. Improving community outreach and partnerships will be important to overcome these challenges and better serve Afghanistan's children.

1. AFGHANISTAN IMMUNIZATION PROGRAM

3. BASIC DATA Population: estimated 28 million [more than 50% under 18 years] (2008) Kabul 2,536,300 ,Kandahar 450,300, Herat 349,000 (Central Statistics Office, 2006) U5MR: 210 per 1,000 live births [600 children under five die every day] Adjusted MMR: is at 1,600 per 100,000 [more than 50 women die every day from complications in pregnancy and childbirth] 54% of Afghan children are stunted and 40% are underweight Average adult illiteracy rate: 71% [female illiteracy as high as 86%] More than 1 million primary school age girls not in school [in two provinces, girls’ non enrolment = 99%] More than 75% of population does not have access to safe drinking water Up to 30% of primary school age children working to support families Early marriage affects many young girls [preventing access to education and increasing health risks] Per capita GDP is US$ 250 [40% of which comes from cultivation and traffic of illicit drugs] Afghanistan has one the highest proportion of school-age (7-12) children in the world: about 1 in 5 Afghans is a school-age child.

4. DISEASE INCIDENCE

5. VACCINE COVERAGE

6. Afghanistan first in world to use new vaccine against polio Four countries in the world have never stopped polio transmission – Afghanistan, India, Nigeria and Pakistan Kabul, 15 December 2009 – A new vaccine against polio will be used for the first time today in polio immunization campaigns in Afghanistan. The bivalent oral polio vaccine (bOPV), recommended by the Advisory Committee on Poliomyelitis Eradication, the global technical advisory body of the Global Polio Eradication Initiative as a critical tool to eradicate polio, can provide the optimal concurrent protection needed by young children against both surviving serotypes (types 1 and 3) of the paralysing virus. This will vastly simplify the logistics of vaccination in the conflict-affected parts of this country. This sub-national immunization campaign, from 15-17 December, will deliver bOPV to 2.8 million children under five in the Southern, South-Eastern and Eastern Regions of Afghanistan

7. Afghanistan first in world to use new vaccine against polio Most of Afghanistan is polio-free: 28 out of the 31 children paralysed by polio this year come from 13 highly insecure districts (of 329 districts in the country). In 2009, polio eradication efforts in Afghanistan have focused on improving operations and creating a safe environment for vaccination teams. Nongovernmental agencies have been contracted and local leaders involved to ensure that parties in conflict are approached, safe passage for vaccinators assured and children reached.

8. Afghanistan first in world to use new vaccine against polio Due to such preparations and strengthened supervision and staffing, the proportion of the nearly 1.2 million children under five years old in the Southern Region who could not be reached was reduced from more than 20 per cent in early 2009, down to 5 per cent during the July and September 2009 campaigns. The availability of bOPV multiplies the effect of such improvements. However, in the 13 highest-risk districts of Kandahar and Helmand provinces in the Southern Region, the proportion of children who are still unimmunized is well above 20 per cent – and more than 60 per cent in some areas.

9. POLIO A PERSISTENT PROBLEM While the Global Polio Eradication Initiative, a public-private partnership leading the effort, has reduced the incidence of polio by more than 99 per cent (from an estimated 1000 children affected daily in 1988 to 1483 children in all of 2009 to date) polio still has a foothold in the four endemic countries. The consequences are severe beyond those areas: 16 previously polio-free countries are currently suffering outbreaks following importations of the virus; in four of these, polio transmission has lasted more than a year.

10. IMMUNIZATION RATES 2008 % of routine EPI vaccines financed by government 2008 total 0.0% Immunization 2008, 1-year-old children immunized against: TB, corresponding vaccines: BCG: 85% Immunization 2008, 1-year-old children immunized against: DPT, corresponding vaccines: DPT1ß: 96% Immunization 2008, 1-year-old children immunized against: DPT, corresponding vaccines: DPT3ß: 85%

11. IMMUNIZATION RATES Immunization 2008, 1-year-old children immunized against: Polio, corresponding vaccines: polio3: 85% Immunization 2008, 1-year-old children immunized against: Measles, corresponding vaccines: measles: 75% Immunization 2008, 1-year-old children immunized against: HepB, corresponding vaccines: HepB3: 85%

12. IMMUNIZATION RATES Immunization 2008, 1-year-old children immunized against: Hib, corresponding vaccines: Hib3: NA Immunization 2008, % newborns protected against tetanus: 83% % under-fives with suspected pneumonia taken to an appropriate health-care provider, 2005–2008*: NA Malaria 2006–2008*, % households owning at least one ITN: NA Malaria 2006–2008*, % under-fives sleeping under ITNs: NA Malaria 2006–2008*, % under-fives with fever receiving anti-malarial drugs: NA

13. IMMUNIZATION RATES 2007 Immunization coverage for DPT1, DPT3 and measles is estimated at 88, 76 and 64 per cent respectively Unicef has Immunized over 5 million children against polio and delivered millions of vitamin A supplements The major efforts will be directed towards polio eradication.

14. IMMUNIZATION RATES Measles and TT campaign will be conducted in 21 provinces that have not been covered yet. Polio eradication remains a major challenge in Afghanistan. A massive 4-stage polio campaign to vaccinate more than 7 million children under the age of five has been undertaken by the Government of Afghanistan, UNICEF and WHO Five cases of polio (four type 1& one type 3) have been confirmed since the beginning of 2007 in the districts of Kajaki and Nade-Ali of Helmand, Maiwand of Kandahar, Mehtarlam of Laghman and Jalalabad of Nangarhar province

15. IMMUNIZATION RATES Measles and Tetanus vaccination campaigns were conducted in the Southern and Western Provinces and 396,192 children under the age of 12 and 177,981 women of child bearing age were vaccinated against Measles and Tetanus respectively

16. IMMUNIZATION RATES Health services are available in 82 per cent of districts, there is a significant population without access to such services Two million primary school-aged children (60 per cent) are out of school, with an estimated 1.3 million of them being girls

17. CHALLENGES Since many women in Afghanistan are not allowed to leave their homes alone, a door-to-door approach is essential to reach a maximum number of children. Additionally, in areas that are affected by conflict, reaching children becomes increasingly difficult. Security: We need to be closer to these communities, to work with them directly, to earn their trust and sense of partnership. We need to show communities – who are best placed to negotiate access to and delivery of services – that the work we support for women and children rises above any political differences that may exist in a particular part of the country

18. CHALLENGES Bad weather and heavy snowfall have blocked roads and hindered access to vulnerable communities. The security situation continues to deteriorate. During 2007, approximately 40-50 percent of the districts in the country were not accessible to UN missions for extended periods due to insecurity and movement restrictions

19. CHALLENGES Active military operations particularly in the South and Southeast hamper assessment of affected areas and delivery of humanitarian assistance directly by the UN. As a result of the conflict in the south and west, and attacks aimed at anti-government elements (AGE) by foreign forces, the civilian population has also undergone casualties.

20. CHALLENGES The combined activities of foreign forces in combating AGE as well as engaging in development work through the Provincial Reconstruction Teams has also affected the channeling of aid by governments toward purely development-oriented entities. As security deteriorates, there is a danger of not differentiating between soldiers and aid workers, and challenging people’s perceptions about the neutrality of aid workers.

21. STEPS TO TAKE Given restrictions in access by the UN, there needs to be reliance on NGO implementing partners and monitoring through triangulation. Strengthening and engaging community structures in program delivery will ensure better IDPs are largely short-term and localized but could turn into a long term and chronic problem if military operations continue and Iran and Pakistan impose forced deportation of Afghan refugees. School incidents and an increase in the number of polio cases remain a major concern requiring extensive communication, resource mobilization and strong political support at different levels.

22. STEPS TO TAKE Results, quality and sustainability, and more ownership by communities. Such initiatives are also likely to impede the advances made by the insurgency. UNICEF is looking at a significant partnership with Community Development Councils as part of the Government’s National Solidarity program.

23. STEPS TO TAKE In areas where assistance to communities and project implementation is hampered by insecurity and difficulty in access, realistic opportunities with communities needs to be exploited to make quick and sustainable impact interventions

24. STEPS TO TAKE A rapid assessment of immunization status of children in the country which needs to be in partnership with Ministry of Public Health and other UN agencies and NGOs. Although it is not possible to access the insecure areas for assessment which possibly have the most disadvantaged and underserved population. Initiate community therapeutic vaccination centers closer to communities particularly in the high risk areas taking into account insecurity and managing capacity of MOPH

25. STEPS TO TAKE Over 600,000 vulnerable children among the displaced, returnees, host communities and impoverished will benefit from distribution of essential drugs, micronutrients, measles and Tetanus toxoid (TT) vaccination and rapid response to diarrhea and acute respiratory disease outbreaks

26. VACCINATION FINANCING The vaccination campaign in Afghanistan is financed by the Government of Canada, the second-highest per capita donor to the Global Polio Eradication Initiative with US$260 million in contributions. Canada, which assumes presidency of the G8 in 2010, first placed polio on the group's agenda when it last held the presidency in 2002. The G8 is the single-largest donor bloc to polio eradication.

27. UNICEF SAMPLE FUNDING

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29. SAMPLE FUNDING

30. SAMPLE FUNDING

31. SAMPLE FUNDING

32. GLOSSERY EPI - Expanded Program on Immunization: The immunizations in this program include those against TB, DPT, polio and measles, as well as protecting babies against neonatal tetanus by vaccination of pregnant women. Other vaccines (e.g. against hepatitis B or yellow fever) may be included in the program in some countries.

33. GLOSSERY DPT3 - Percentage of infants that received three doses of diphtheria, pertussis (whooping cough) and tetanus vaccine HepB3 - Percentage of infants that received three doses of hepatitis B vaccine