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The study was aimed at evaluating immunization coverage against Tuberculosis, Poliomyelitis, Diphtheria, Tetanus, Pertussis and Measles. The data was taken from a sufficiently large study that adopted multi stage and systematic random sampling. The current paper aims at reporting the evaluated coverage in Bellary district and discusses addressing gaps in coverage of vaccine preventable diseases. We have reported in our earlier papers that parental recall was better than immunization card for reflecting immunization coverage, and improvement in immunization coverage was due to special immunization sessions (catch up sessions) and supportive supervision. In this paper, we present the estimates of vaccine coverage under national program. We also discuss the shortfalls responsible for drop in immunization coverage.
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*Address for correspondence:
Dr.Giridhara R Babu, MBBS, MPH, MBA,PhDc,
Assistant Professor, Public Health Foundation of India,
Indian Institute of Public Health – Hyderabad,
Plot no # 1, Anv Arcade, Amar Co-op Society, Kavuri Hills,
Madhapur, Hyderabad 500081.
DOI: 10.5530/ijmedph.3.2011.4
Evaluation of Immunization Services in high-risk
district in India
Giridhara R Babu1,2*, Jørn Olsen3, Sayantee Jana4, Siddhartha Nandy5, Muhammad N Farid6,
Sadhana SM7, Shridhar Kadam8
1Department of Epidemiology, School of Public Health, University of California, Los Angles, CA 90024, USA. 2Public Health Foundation
of India, Indian Institute of Public Health – Hyderabad, Plot no # 1, Anv Arcade, Amar Co-op Society, Kavuri Hills, Madhapur, Hyderabad
500081. 3Department of Epidemiology, School of Public Health, University of California, Los Angles, CA 90024. USA. 4Indian institute of public
health, Public Health Foundation of India, Campus of Indian Institute of Health and Family welfare, Vengalrao nagar, Hyderabad 500038,
India. 5Indian institute of public health, Public Health Foundation of India, Campus of Indian Institute of Health and Family Welfare, Vengalrao
nagar, Hyderabad 500038, India. 6Department of Epidemiology, School of Public Health, University of California, Los Angles, CA 90024, USA.
7Victoria foundation, JP Nagar, Bangalore 560078, India. 8Indian Institute of Public Health, Bhubaneshwar, India
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Pertussis and Measles. The data was taken from a sufciently large study that adopted multi stage and systematic
than immunization card for reecting immunization coverage, and improvement in immunization coverage was due to
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Smallpox was declared eradicated in 1975 subsequent to
effective vaccination programs and strengthened surveillance
for the disease. The success of Smallpox led to launching
of the Expanded Programme on Immunization (EPI) in
India in 1978 to control other Vaccine Preventable Diseases
(VPD). In 1978, EPI coverage was included for six diseases:
diphtheria, pertussis, tetanus, poliomyelitis, typhoid and
childhood tuberculosis. The aim of EIP was to cover 80%
of all infants. Subsequently, the programme was universalized
and renamed as Universal Immunization Programme (UIP)
in 1985. Measles vaccine was included in the programme
and typhoid vaccine was discontinued. The UIP was
introduced in a phased manner from 1985 to cover all
districts in the country by 1990, targeting all infants with
the primary immunization schedule and all pregnant women
with Tetanus Toxoid immunization.1-2
Earlier evaluations of routine Immunization in India have
shown wide differences between reported coverage by local
health agencies compared to evaluated coverage.[3-6] Hence,
it is important to ascertain the evaluated immunization
coverage for all the vaccines used in UIP and to determine
if there is any improvement in terms of immunization
coverage. Identication of reliable source of Immunization
history is important to evaluate Immunization coverage in
developing countries like India. Our study aims at evaluating
the sources of data in a high-risk district in Karnataka,
Our objective is to evaluate the coverage of immunization
antigens in the district of Bellary.
Babu GR, et al.: Evaluation of Immunization Services in high-risk district in India
18 !"#$%&$%'()$%*+,-./%0(1-#0%2333$.45()60$789:% ;% &+-<=>(6#(5,(8%?@AA% ;% B7-%A% ;% !CC+(%D
After identication of the houses to be surveyed, the adult
individuals in the identied houses would provide complete
information regarding the conduct of study. A brochure
containing the details of the study will be handed over to them.
Consent will be taken after duly explaining the objectives,
methods and implications of the study. The participation in
the study was voluntary and the subjects could have withdrawn
from the study at any point of time during the survey.
All the eight taluks of Bellary were included in the study.
By random sampling, however, 1632 houses were surveyed
in the seven sub districts of Bellary district, Karnataka.
After data check and validation, a total of 1632 parent’s
response was included in the survey data. The data
corresponds to information about 1632 children residing
in Bellary district, Karnataka.
In each of this village the surveyors would interview 20
houses in the following manner: First house will be selected
based on the random method of picking up houses.
Eligibility criterion for the selection of any house will be:
House having at least one child birth in the last two years.
Thus the study period will comprise of calendar years starting
from 1st April 2005 till 31st March 2007. From the rst
house, every 3rd house visited in the entire village adding
up to 20 houses. If any house did not contain any live births
in the past two years, the next house will be selected based
on the eligibility criterion.
The analysis was done at University of California, Los
Angeles with permission of IRB from University of
California Los Angeles for data analysis.
Sources of Data
First, the collection of information about immunization
history was sought from interviews of parents. Second,
the information regarding immunization was also obtained
independent of the information through interview, by cross
checking the details on immunization cards of children.
We chose the district of Bellary, which had 18 conrmed
cases of Poliomyelitis in the year 2003. It was reported
that failure to implement routine immunization services
was predominant reason for emergence of polio
transmission in many districts like Bellary in India. This
community-based study of children aged 0-2 years was
carried out in Bellary district during the month of
September 2007. Multistage cluster sampling was used
for the selection of sample. We collected complete list
of taluks (administrative blocks in district) and villages
in Bellary district. After considering different sample
designs,7-10 The study used a multi stage random cluster
sample of children in the age group of 0-12 months for
collection of data. All the taluks were included for the
study. In the rst stage, two primary health centres (PHC)
were selected in each Taluk based on randomly selected
number from random table. In the second stage, in each
of the PHC, two villages were randomly selected from
the list of villages using random number table. In the third
stage, the surveyors would pick up the rst house randomly
and then would interview 20 houses in the following
manner: First house will be selected based on the random
method of picking up houses. The guideline for picking
the rst house was that pick any house randomly from
the micro plan prepared for the purposes of implementing
polio special immunization rounds (SIAs). The micro plans
for SIAs are updated every round and are expected to be
complete for all the villages.
The eligibility criterion for the selection was any house
having at least one child birth in the last two years. Thus
the study period will comprise of calendar years starting
from 1st April 2005 till 31st March 2007. From the rst
house, every 3rd house visited in the entire village adding
up to 20 houses. If any house do not contain any live births
in the past two years, the next house will be selected based
on the eligibility criterion.
Figure 1 Figure 2
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Babu GR, et al.: Evaluation of Immunization Services in high-risk district in India
immunization was 86.5%. The difference between these
two sources of data is signicant since the condence
intervals are non- overlapping.
The inter-dose drop-out rates for antigens are almost similar
for same source of Data, and the common point for both
data sources is that the maximum drop out occurs in the
time period between DPT3/OPV3 to Measles. (Figure 3).
This suggests that the maximum drop out occurs in the
time period between DPT3/OPV3 to Measles. DPT and
OPV are given at monthly intervals and Measles is
administered at 9 completed months since birth.
There is considerable literature available on evaluation of
Immunization coverage in different areas of India.11-20 Our
earlier study21 showed that the information from parental
recall is comparable to the data from BCG scar for BCG,
and has higher specicity compared to Immunization
Third, in the event where immunization cards are not
available, the same details were obtained by Immunization
register maintained in each village by the ICDS worker
present in the village. Finally, the information for BCG
scar was obtained by cross checking the BCG scar present
generally on the lateral side of the left arm. This too was
obtained independent of information obtained from the
interviews. The information obtained by rst above was
classied as parental recall, second and third were classied
as card and fourth was classied as scar.
Data entry and analysis
All the information obtained was entered in a master sheet
corresponding to the village by the interviewer. The coded
information was entered village wise in Microsoft excel.
The names and all other personal identication measures
were removed from the data before data analysis. Initial
data analysis was performed using SPSS for Windows (Rel.
11.0.1. 2001. 17.0, R 2.11. Chicago: SPSS Inc). The output
for this paper was generated using SAS software.
(Copyright, SAS Institute Inc. SAS and all other SAS Institute
Inc. product or service names are registered trademarks or
trademarks of SAS Institute Inc., Cary, NC, USA)
Out of the 1630 children were surveyed, we included only
1110 children between 9-24 months of age for our study.
We assessed immunization coverage according to the source
of data: on the basis of card alone, on the basis of BCG
Scar and card; and on the basis of parental recall. On
analyzing information in cards, it was found that around
98% children received all the doses except measles whose
coverage was 96%. According to card, complete immunization
was found to be 96%. On the basis of parent’s recall about
their child’s immunization status, the coverage of complete Figure 3
Table 1: National immunization shedule-India
Beneficiary Age Vaccine
Infants Birth BCG* and OPV**
6 weeks DPT & OPV
10 weeks DPT & OPV
14 weeks DPT & OPV
9 months Measles vaccine
18 months DPT & OPV (Booster dose)
Children 5 years DT vaccine
10 years Tetanus Toxoid
16 years Tetanus Toxoid
*At birth or at the time of DPT/OPV;
**dose called as Zero dose and can be given till 14 days of age, if missed early.
Abbreviations: BCG = Bacillus calmittee Guerin; DPT = Diphtheria, Pertussis &
Tetanus; OPV = Oral Polio Vaccine; DT = Diphtheria & Tetanus vaccine.
Table 2: Composition of Survey subjects
Total number of individual surveyed Number
All children 1630
Girls 830
Boys 790
Ratio (Girl : Boy) 1.05
Eligibility criterion for complete immunization
(Children of age [9, 24] months)
Girls 548
Boys 562
Immunization Card Holder 888
Girls 460
Boys 428
Babu GR, et al.: Evaluation of Immunization Services in high-risk district in India
20 !"#$%&$%'()$%*+,-./%0(1-#0%2333$.45()60$789:% ;% &+-<=>(6#(5,(8%?@AA% ;% B7-%A% ;% !CC+(%D
from parental recall provides realistic and more conservative
improvements in coverage for all antigens compared to
information from the cards. We found that the improvement
in immunization coverage was due to special immunization
sessions (catch up sessions) and enhanced supervision due
to the newly implemented Immunization programme under
Reproductive and Child Health Project-II of Government
of India. Our study found poor state and district level
supervision as the predominant reason for the poor
immunization coverage against vaccine preventable diseases.
Other reasons include ineffective plan for social mobilization
and the inability of local Governments to improve routine
immunization services in the high-risk areas. In the absence
of other external evaluations, the District Level Household
survey (DLHS) conducted by National Family Health Survey
in 2006 can be taken as background immunization rate in
the district. DLHS-1 was conducted in the years 1998-99
and DLHS-2 was conducted in the years 2002-04.
Further, steps should be taken to address missing children
for follow-up between DPT3/OPV3 to Measles as maximum
drop out occurs in this period.
We have reported the evaluated coverage for several antigens
including inter-dose dropouts for several antigens.
Our study submitted earlier elsewhere21 compared sources
of data with BCG scar as gold standard, whereas earlier
studies have used either Immunization cards11 or prospective
history as gold standard. Developing countries like India
may not consider either Immunization card or prospective
history as gold standard to compare other data sources
since these countries have ineffective immunization card
utilization absence of any reliable registry data. BCG
vaccination offers unique opportunity to cross check
reliability of other data sources by permanent scarring. The
absence of such gold standards for other antigens makes
it difcult for such comparisons. In the absence of parental
recall, use of modern epidemiological methods can be made
for estimation of immunization coverage.24-28 Hence in this
paper, we have submitted the comparisons of evaluated
coverage’s of VPD antigens by both sources of data
comparing the gold standard.
Our earlier papers have demonstrated that “supportive
supervision” and implementation of “special “catch-up”
immunization sessions (conducted in Bellary district during
the months of July and August of the year 2007) were
responsible for the improvement in immunization
coverage.29-30 Complete immunization is dened as the
completion of BCG dose at birth (or later), three doses of
DPT and OPV with 4 weeks gap in between Measles before
the age of 1 year. Based on this, and our earlier study, we
have relied on information from parental recall. Information
Table 3: Summary estimates of immunization evaluation- Bellary district
Antigen Dose Estimates Confidence intervals
Immunization card retention 82.7 (80.41, 84.95)
Immunization system access OPV 0 67.9 (65, 70.78)
BCG parental recall 94.35 (92.84, 95.86)
BCG card 98.4 (97.57, 99.23)
BCG scar 92.44 (90.85, 94.04)
DTP 1 parental recall 94.7 (93.16, 96.25)
DTP 1 card 98.24 (97.36, 99.13)
OPV 1 parental recall 94.61 (93.06, 96.16)
OPV 1 card 98.6 (97.8, 99.38)
DTP 2 parental recall 93.88 (92.23, 95.53)
DTP 2 card 98.57 (97.77, 99.37)
OPV 2 parental recall 94.01 (92.38, 95.64)
OPV 2 card 98.57 (97.77, 99.37)
DTP 3 parental recall 92.98 (91.21, 94.74)
DTP 3 card 98.32 (97.44, 99.19)
OPV 3 parental recall 93.11 (91.35, 94.87)
OPV 3 card 98.29 (97.41, 99.18)
Measles parental recall 87.31 (84.89, 89.72)
Measles card 96.62 (95.32, 97.92)
Complete Immunization Scar and Card 93.22 (91.36, 94.08)
All Card 95.95 (94.51, 97.4)
Parental recall 86.5 (83.96, 89.09)
Scar and recall 82.67 (79.82, 85.52)
!"#$%&$%'()$%*+,-./%0(1-#0%2333$.45()60$789:% ;% &+-<=>(6#(5,(8%?@AA% ;% B7-%A% ;% !CC+(%D% 21
Babu GR, et al.: Evaluation of Immunization Services in high-risk district in India
17. Singh P, Yadav RJ. Immunisation status of children in BIMARU sta tes.
Indian J Pediatr 2001 Jun; 68(6):495-500.
18. Ray SK, Dasgupta S, Dobe M, Biswas R, Mehta P, Baishya AC. An
evaluation of routine immunization coverage in some districts of West
Bengal and Assam. Ind J Pub Hlth 2004; 48:82-85.
19. Singh MC, Badole CM, Singh MP. Immuniza tion coverage and the
knowledge and practice of mothers regarding immunization in rural area.
Indian J Pub Hlth 1994; 38:103-107.
20. Tandon BN, Gandhi N. Immunization coverage in India for areas served by
the Integrated Child Development Services programme. The Integrated
Child Development Services Consultants. : Bull World Health Organ1992;
21. Giridhara R Babu , Jorn Olsen , Sayantee Jana ,Siddhartha Nandy,
Muhammad Farid, VJ Sadhana. Evaluation of Immuniza tion Cards And
Parental Recall Against Gold Standard For Evaluating Immunization
Coverage. The Internet Journal of Epidemiology. 2011 Volume 9 Number
2 web: IJE.
22. Singh : Record-Based Immunization Coverage Assessment in Rural
North India The Internet Journal of Third World Medicine. 2007 Volume 4
Number 1.
23. Jishnu Das, Saumya Das, Tr ust, learning, and vaccination: a case study of
a North Indian village, Social Science and Medicine, Volume 57, Issue 1,
July 2003, Pages 97-112.
24. Boerma, J. T., Sommerfelt, S., Rutstein, S., Rojas, G. (1990) Immunization:
Levels, Trends and Differentials. Comparative Studies No. 1. Demographic
and Health Surveys. Institute for Resource Development, Columbia.
25. Giridhara R Babu (2008). Comment on ‘From risk factors to explanation in
public health’. J Public Health, 30:515-516.
26. Greenland S, Neutra R (1980). Control of confounding in the assessment
of medical technology. Int J Epidemiol,9:361-367.
27. Greenland S, Lash TL (2008). Bias Analysis. In: Rothman KJ, Greenland S,
Lash TL (ed). Modern Epidemiology, 3rd edn. Lippincott Williams and
Wilkins, Philadelphia, pp 348-352.
28. Rothman KJ, Greenland S, Lash TL (2008). Precision and statistics in
epidemiologic studies. In: In: Rothman KJ, Greenland S, Lash TL (ed).
Modern Epidemiology, 3rd e d n. L ip p in co tt W il li a ms an d Wi lk i ns , Ph il a de lp h ia ,
pp 132-34.
29. Giridhara R Babu, Vivek V Singh, Sadhana SM, Siddhartha Nandy, Sayantee
Jana, Sathyanarayana TN. Supportive supervision and Immunization
Coverage: Evidence from India. The Internet Journal of Epidemiology. 2011
Volume 9 Number 2. The Internet Journal of Epidemiology. 2011 Volume 9
Number 2. Web: Internet Journal of Epidemiology.
30. Giridhara R Babu, Sayantee Jana, Siddhar tha Nandy, Jørn Olsen,
Muhammad N Farid, Sadhana SM. Role of Catch-up campaign in Developing
countries: A success story from India. Annals of Tropical Medicine and Public
Health [Under peer review].
1. Government of India. National Child Sur vival and Safe Motherhood
Programme. New Delhi: Ministry of Health and Family Welfare; 1994.
2. Patowary A, Jaiswal O, Lal S, Govila A, Pratinidhi A, Sharma A, Swain S,
Gupta S, Joseph A, Sawhney N, Chakraborty A, Maitra K, Chandrasekhar
C, Mathur A, Saxena N, Saxena B. Coverage Evaluation Survey Of
Immunization In Eleven States Of India.Indian J Community Med 1990;
3. Lim SS, Stein DB, Charrow A, Murray CJ. Tracking progress towards
universal childhood immunisation and the impact of global initiatives: a
systematic analysis of three-dose diphtheria, tetanus, and per tussis
immunisation coverage. Lancet2008; 372:2031-46.
4. Coutinho L, Bisht S, Raje G. Numerical narratives and documentary
practices: vaccines, targets and reports of immunisation programme.
Econ Polit Wkly2000; 35:656-66.
5. Sokhey J. The Immunization Programme In India. Indian J Community
Med 1990; 15:163-172.
6. Mukherjee B, Ray SK, Kar M et al. Coverage evaluation surveys amongst
children in some blocks of West Bengal. Ind J Pub Health. 1990; 34(4);
7. Bennett A et al. A computer simulation of household sampling schemes
for health surveys in developing countries. International Journal of
Epidemiology, 1994, 23:1282-1291.
8. Harris DR, Lemaeshow S. Evaluation of the EPI survey methodology for
estimating relative risk. World Health Statistics Quarterly, 1991, 44:107-113.
9. Lemeshow S, Robinson D. Surveys to measure programme coverage and
impact: a review of the methodology used by the Expanded Programme
on Immunization. Wor ld Health Statistics Quarterly, 1985, 38:65-75.
10. Reichler MR et al. Cluster survey evaluation of coverage and risk factors
for failure to be immunized during the 1995 National Immunization Days
in Egypt. International Journal of Epidemiology, 1998, 27:1083-1089.
11. Singh P and Yadav R.J. Immunization status of children of India. Indian
Pediatric 2000; 37:1194-1199.
12. Suresh K, Saxena D. Trends and determinants of immunization coverage
in India. J Indian Med Assoc 2000; 98:10-14.
13. International Institute for Population sciences (IIPS) and ORC Macro.1994
National Family Health Survey (NFHS-1), 1992-1993: India. Mumbai: IIPS.
14. International Institute for Population sciences (IIPS) and ORC Macro. 2000.
National Family Health Survey (NFHS-2), 1998-1999: India. Mumbai: IIPS.
15. Bhatia V, Swami HM, Rai SR, Gula ti S, Verma A, Parashar A, Kumari R.
Immunization status in children. Indian J Pediatr 2004 Apr; 71(4):313-315.
16. Kar M, Reddiah VP, Kant S. Primary immunization status of children in
slum areas of South Delhi- the challenge of reaching urban poor. Indian
J Community Med 2001; 26:151-154.
... Based on vaccination card and history, 69.5% of the children aged 12-23 month were fully immunized. It was lower than reported in Indian studies 98% and 72.23% [13,14] Hadramout study 82.4% [11], in the Ethiopian study 75.5% [15], but higher than other India study 58.6 % and 57.6% [16]. Our study was also higher than that in Ethiopia study 35.6% [17]. ...
Full-text available
Introduction: At least 2 million people die every year from diseases preventable by vaccines recommended by the World Health Organization. Objective: To assess the routine immunization coverage among children aged 12-23 month and to determine the reasons for unvaccinated. Methods: We conducted a community-based survey in Al-Taizyah district, Taiz governorate, Yemen. Information about vaccination status and related barriers was collected for 420 children from 1stMarch to 31stMarch 2012. Results: 49.8% of the children had vaccination cards. About 69.5% of the children were fully vaccinated by cards and by history, 15.5% were partially vaccinated and 15% not vaccinated. As a regards to crude vaccination coverage, 82.9% of children were received BCG vaccine. OPV1 vaccine was 82.6%. Pentavalent1 was 82.6%. Measles 1 represented for 71.7% and vitamin A1 was 46.4%. 91% was valid doses for OPV1 and 93% for pentavalent1. Only 76% of measles1 dose was valid. The high scores14% of drop-out rate was recorded between BCG and Measles. The main reasons for partially vaccinated and unvaccinated of children were the lack of information 61.7%. Conclusion: There is low vaccination coverage among children aged 12-23 months. There is a need to raise the awareness of community about vaccination and EPI services in Al-Taizyah district. © Indian Association of Preventive and Social Medicine. All rights reserved.
Full-text available
In this paper, authors have used operation definition of Supportive supervision to studying its role in improving immunization coverage in developing country settings. Comparison of immunization coverage before and after the initiation of supportive supervision is analyzed. Despite of methodological limitations, the study infers that supportive supervision improves immunization coverage and also serves an efficient tool to strengthen the local health system.
Objective: Recent studies and surveys are observing a declining trend of routine immunization coverage and fully immunized children in India are reported to be 38%. A rapid assessment technique was used on National Immunization Day (PPI) to assess the immunization status among children in the age group of 12-23 months covering urban, rural and slum areas in UT, Chandigarh. METHODS: The study covered 796 children in proportion of their distribution in urban, rural and slum areas. RESULTS: Evaluation recorded fully immunized children as 72.23%, partially immunized as 22.99% and unimmunized as 4.64%. Only 58.66% children in urban slums were fully immunized. The overall coverage for various vaccines was BCG: 93.09%, DPT1/OPV1: 93.97%, DPT2/OPV2: 90.57%, DPT3/OPV3: 85.92% and measles: 76%. No sex-wise difference was noticed in the study. CONCLUSION: Efforts must be made to strengthen routine immunization programme especially in the underprivileged groups and areas such as slum in cities so that target of universal coverage can be achieved as envisaged at national level.
The documentary practices of target-setting, reporting, evaluation and supervision at the level of the district and the primary health centres are built around a bureaucratic organisation of information and allow for the production of 'numerical narratives' to fulfil the needs of the bureaucratic imagination of a successful public health programme wherein the record gains primacy over the event. Front-line health workers, ANMs are the focus of the analysis here, as they constantly negotiate between the health bureaucracy and the communities (local bureaucracies). This article demonstrates how programmatic goals are mediated by local contexts through these health workers, and how their perceptions and practices produce numerical narratives which meet the demands of rule and record bound bureaucratic imagination.
The immunization Programme was started in India in 1978 with the objective of reducing the mortality due to vaccine preventable diseases. Immunization coverage levels in infants and pregnant women have increased substantially over the last decade. Immunization coverage levels of 69 to 82% with various vaccines were reported in 1989-90. There is however, a wide disparity in the coverage levels in states and in the districts. While the priority to remains to increase immunization coverage levels, surveillance of vaccine preventable diseases is receiving high priority to identify weak pockets for intensification of immunization services and to document impact. Besides completeness of reporting., emphasis of the surveillance system in many areas has shifted to obtaining information on cases as early as possible to allow epidemiological investigations and effective follow-up action. The achievements in a large number of districts show that the goal of universal immunization, while difficult and challenging, is attainable.
Background: Substantial resources have been invested in increasing childhood immunisation coverage through global initiatives such as the Universal Childhood Immunisation (UCI) campaign and the Global Alliance on Vaccines and Immunisations (GAVI). There are longstanding concerns that target-oriented and performance-oriented initiatives such as UCI and GAVI's immunisation services support (ISS) might encourage over-reporting. We estimated the coverage of three doses of diphtheria, tetanus, and pertussis vaccine (DTP3) based on surveys using all available data. Methods: We estimated DTP3 coverage by analysing unit record data from surveys and supplemented this with reported coverage from other surveys and administrative data. We used bidirectional distance-dependent regression to estimate trends in survey-based coverage in 193 countries during 1986-2006. We used standard time-series cross-sectional analysis to investigate any association in the difference between countries' official reports and survey-based coverage as the dependent variable and the presence of GAVI ISS as the independent variable, controlling for country and time effects. Findings: Crude coverage of DTP3 based on surveys increased from 59% (95% uncertainty interval 51-65) in 1986 to 65% (60-68) in 1990, 70% (65-74) in 2000, and 74% (70-77) in 2006. There were substantial differences between officially reported and survey-based coverage during UCI. GAVI ISS significantly increased the difference between officially reported coverage and survey coverage. Up to 2006, in 51 countries receiving GAVI ISS payments, 7.4 million (5.7 million to 9.2 million) additional children were immunised with DTP3 based on surveys compared with officially reported estimates of 13.9 million. On the basis of the number of additional children immunised from surveys at a rate of US$20 each, GAVI ISS payments are estimated at $150 million (115 million to 184 million) compared with actual disbursements of $290 million. Interpretation: Survey-based DTP3 immunisation coverage has improved more gradually and not to the level suggested by countries' official reports or WHO and UNICEF estimates. There is an urgent need for independent and contestable monitoring of health indicators in an era of global initiatives that are target-oriented and disburse funds based on performance.