In 2001, Gavi, the Vaccine Alliance, supported by a large grant from the Bill and Melinda Gates Foundation, was launched to reinvigorate the drive to protect children from vaccine-preventable diseases. The Alliance was founded on the principle of fairness. Poverty, or the place where a child was born, should not determine access to life-saving vaccines, including the newer and more expensive ones. Every child deserves the best that science can offer. The Alliance was also a tribute to the power of innovation to move the human condition a big step forward. A world that could put a computer in every home could surely put vaccines in every child.
By 2007, Gavi and its partners, including WHO, had revitalized immunization as a strategy for averting millions of childhood deaths each year. The new rotavirus and pneumonococal vaccines raised hope that diarrhoea and respiratory infections – the two biggest childhood killers – could be more routinely prevented.
In 2010, the Decade of Vaccines was launched at the World Economic Forum as an effort, supported by multiple stakeholders, to extend the full benefits of immunization to all by 2020. To support this goal, the World Health Assembly approved the ambitious Global Vaccine Action Plan in 2012 as the framework for delivering universal access to vaccines.
The Vaccine Action Plan has been described as “one of the largest and most ambitious public health initiatives ever launched”. It set new targets for the decade, defined their indicators, proposed six strategic objectives and the actions needed to achieve them, and provided an initial estimate of resource requirements and return on investment.
WHO’s Strategic Advisory Group of Experts (SAGE)
As a contribution to measurement and accountability, WHO’s Strategic Advisory Group of Experts (SAGE) on immunization has issued annual progress reports on implementation of the plan. The 2016 report provides a careful analysis of progress and challenges at the midpoint in the decade. Despite some bright spots in global immunization efforts, the overall picture is sobering.
On the bright side, more children are being immunized worldwide than ever before, with the highest level of routine coverage in history. Indigenous measles and rubella have been eliminated from the Americas, and maternal and neonatal tetanus has been eliminated in South-East Asia.
Since 2010, 99 low- and middle-income countries have introduced one or more new or underutilized vaccines, exceeding the target set out in the action plan. While data are not yet available to quantify the associated impact on child health, the steep decline in morbidity and mortality from pneumonia and diarrheal disease recorded in some countries that introduced the pneumococcal and rotavirus vaccines suggests that the contribution will be substantial.
At the same time, sustainability is an issue of growing concern. Even very poor countries have used domestic resources to support free immunization services as a public good. As more countries progress to middle-income status, they lose their eligibility for financing from GAVI, raising questions about whether introduction of the newer and more expensive vaccines can be fully financed from domestic budgets.
The success of the polio eradication initiative raises additional long-term concerns. For example, the 2016 outbreaks of urban yellow fever in Angola and the Democratic Republic of Congo prompted the largest emergency vaccination campaign ever undertaken in Africa. A crisis was averted, partly because countries could draw on the experience, massive infrastructure, and human resources of polio programmes already in place.
On the R&D front, substantial progress was recorded in developing vaccines for HIV, malaria, dengue, and tuberculosis. However, that progress underscores the urgent need to expand clinical trial capacity and strengthen the procedures used by national regulatory authorities to evaluate and license vaccines and technologies in the developing world. These needs are being addressed by two WHO initiatives: the African vaccine regulatory forum and a network of vaccine regulators from developing countries.
“Progress is feasible in any determined country.”
Dr Chan, WHO Director-General
New platform delivery technologies are also being developed to make vaccines easier to safely store, transport, deliver, and administer. These technologies, once tested, licensed, and deployed at scale, will have a powerful impact on health and well-being around the world. They will enable many countries to expand immunization to reach even the most remote and vulnerable populations.
Yet, as the SAGE assessment revealed, progress towards other key targets has been sluggish and is woefully inadequate to meet the soaring ambitions of the action plan. Halfway through the decade, global targets set for maternal and neonatal tetanus, measles, and rubella, all slated for elimination, were missed by a long shot. Although more infants than ever before are receiving the critical third dose of diphtheria-tetanus-pertussis vaccine, global coverage of these basic vaccines has increased by only 1% since 2010, putting one of the plan’s most important targets seriously off track. In 2015, 68 countries fell short of the target to achieve at least 90% national coverage with the third dose. Some 26 countries reported no change in coverage levels and 25 countries reported a net decrease.
The SAGE experts commended the 16 countries that made good progress, especially in reaching vulnerable and marginalized populations. Their success confirms that progress on immunization can be achieved with strong domestic leadership, smart and sustained investments, and effective accountability mechanisms. Some countries with the highest number of unvaccinated children made the most progress, including the Democratic Republic of Congo, Ethiopia, and India. While these countries did not meet the target, all are moving in the right direction.
The long-standing problem of poor quality data persists, impairing the identification of populations that are being missed and the design of targeted corrective strategies. Replacing guesswork with solid data can bring surprises. After improving the accuracy of its immunization data, Mexico found that immunization coverage was actually 10% lower than previously thought. By making pockets of missed people visible, Mexico was able to make them a priority for remedial action.
Success stories in individual countries brighten the sobering picture considerably. Beginning in 2010, India made new investments in health systems, replacing and repairing cold chain equipment, training and accrediting thousands of social health activist workers, and using micro-planning to support immunization. These improvements and the intensification of services through special campaigns resulted in coverage jumping from 79% to 87%. In numbers, that meant two million more children received vaccination services in 2015 than in 2010.
Chad used the “Reaching every community” strategy to achieve hard-won coverage gains that rose from 39% to 55%, proving that progress is feasible in any determined country. Like Mexico, Uganda took risks to change systems and improve outcomes for the better even if the payoff is yet to come.
The assessment also revealed a general failure to appreciate the broader value-added benefits that a well-performing immunization programme brings to overall health care. When systems for vaccine procurement and delivery operate as a fully integrated component of a health system, they can drive the move towards universal health coverage.
Moreover, immunization has become a fundamental strategy for achieving more recent health priorities, from preventing liver and cervical cancer – the biggest causes of cancer in the developing world – through hepatitis B and human papilloma vaccines, to curbing antimicrobial resistance, to providing a platform for improving antenatal and newborn care and meeting the long-neglected needs of adolescents.
WHO is now challenging international and national health leaders to make immunization not only one of the biggest success stories of modern medicine, but the greatest success story ever. Technically, this is entirely feasible. Full implementation of the Global Vaccine Action Plan remains the best route for doing so. In a world where vast social inequalities create unrest and disturbing instability, the game-changing power of universal coverage with safe, protective, and cost-effective vaccines deserves a much higher profile.