“Last year immunization led to some notable wins in the fight against polio, rubella and maternal and neonatal tetanus,” says Dr Margaret Chan, WHO Director-General. “But they were isolated wins. Polio was eliminated in one country, tetanus in three, and rubella in one geographical region. The challenge now is to make gains like this the norm.”
Immunization averts 2 to 3 million deaths annually; however, an additional 1.5 million deaths could be avoided if global vaccination coverage improved. Today, an estimated 18.7 million infants – nearly 1 in 5 children – worldwide are still missing out on routine immunizations for preventable diseases, such as diphtheria, pertussis and tetanus.
In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan (GVAP), a commitment to ensure that no one misses out on vital immunizations. Despite gains in vaccination coverage in some regions and countries the past year, global vaccination targets remain off track.
Only 1 out of 6 targets is on track—the introduction of new or underutilized vaccines in low- and middle-income countries. During the past five years, 86 low- and middle-income countries have made 128 introductions of the following vaccines: Hib-containing vaccine, pneumococcal conjugate vaccine (PCV), rotavirus vaccine, human papillomavirus vaccine (HPV), rubella and inactivated polio vaccine. The target is at least 90 low- and middle-income countries by 2015.
Game-changers in immunization
Last year saw some major breakthroughs.
India joined Cambodia, Mauritania and Madagascar in eliminating maternal and neonatal tetanus. It also improved coverage of the diphtheria-tetanus-pertussis-containing vaccines (DTP3) to 83%.
Despite challenges imposed by Ebola, including for routine immunization coverage, the African Region became one-step closer to being certified polio-free with the removal of Nigeria from the list of polio-endemic countries. As recently as 2012, the country accounted for more than half of all polio cases worldwide. Now, only two countries – Afghanistan and Pakistan – remain polio endemic.
The Region of the Americas became the first to eliminate rubella, a contagious viral disease that can cause multiple birth defects as well as fetal death when contracted by women during pregnancy.
Additionally, five years after the introduction of an affordable conjugate meningitis A vaccine, immunization of more than 230 million people has led to the control and near elimination of deadly meningitis A disease in the African “meningitis belt” that stretches from Senegal to Ethiopia.
New vaccines against dengue, Ebola and malaria have the potential to be game-changers in immunization in the near future. For example, through a “ring-vaccination” strategy, the Ebola vaccine is being given to anyone who has come into contact with a person infected with Ebola, as well as contacts of theirs.
And, the new polio vaccination regimen, with the withdrawal of type 2 oral polio vaccine in 155 countries this month, represents a critical step towards a polio-free world.
“Although the world has seen some achievements in immunization, global vaccination coverage has stalled the past few years,” says Dr Flavia Bustreo, WHO Assistant Director-General Family, Women and Children’s Health and Vice Chair of Gavi, the Vaccine Alliance Board. “Far too many opportunities to reach unvaccinated children and close the immunization gap are still being missed every day.”
Reducing missed opportunities
To improve vaccination coverage, WHO is calling on countries to reach more children missed by routine delivery systems, especially those living in countries, districts or areas where less than 80% of them are receiving vaccines or those living in countries affected by conflicts or emergencies.
More than 60% of children who are unvaccinated live in 10 countries: the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Iraq, Nigeria, Pakistan, the Philippines, Uganda and South Africa.
Equally, when a child or adult who is unvaccinated or not fully vaccinated visits a health facility for any reason, their vaccination record should be checked by healthcare workers and they should be given all vaccines they are missing.
However, recent field assessments in American and African Regions have shown that between 23-96% of eligible children who visited a health facility for vaccination or for medical care, left the health facility without receiving the vaccine doses they needed.
“These children are not what we would consider ‘hard-to-reach’ or underserved populations,” says Dr Jean-Marie Okwo-Bele, Director of Immunization, Vaccines and Biologicals at WHO. “Children who are already present in health facilities are easy wins in improving vaccination coverage.”
Getting back on track
Many of the successes achieved last year resulted from strengthened leadership and accountability at all levels—national, regional and global.
“When countries and partners establish and enforce clear accountability systems, measure results and take corrective action when results are not achieved, gaps in immunization can be closed,” adds Dr Okwo-Bele.
Last year, the Strategic Advisory Group of Experts on Immunization (SAGE) identified 5 factors to achieving significant results in immunization coverage:
- quality and use of data
- community involvement
- better access to immunization services for marginalized and displaced populations
- strong health systems
- access to vaccines in all places at all times
In strengthening the quality and use of data, the World Health Assembly passed a resolution last year on vaccine pricing, which called on countries to provide their vaccine prices to WHO. The WHO database currently contains 1600 vaccine price records on almost 50 different types of vaccines from 42 countries, but also from international buyers such as the procurement platform available in the WHO Region of the Americas and from UNICEF, making it the largest international vaccine price database.
Because prices paid for vaccines represent a large share of countries’ immunization budgets and the prices of new vaccines are higher than those of traditional vaccines, costs represent a strong barrier to countries introducing new vaccines.