Commentary – Isolated gains in immunization need to become the norm
Dr Jean-Marie Okwo-Bele, Director of the Department of Immunization, Vaccines and Biologicals, WHO

11 December 2015
Ten days and more than 11 million children vaccinated against measles and rubella – that’s 764 children reached every minute. These numbers continue to impress me when I think about last year’s game-changing immunization programmes that reached children often missed due to humanitarian emergencies.

In Yemen, for example, despite the ongoing conflict, fuel shortages and block roads, the country’s 2014 immunization campaign was able to reach 91% of children aged nine months to 15 years. Remarkably, parents brought their children to the clinics and more than 24 000 health workers were mobilized across the country to administer a newly introduced measles-rubella vaccine.

With strong government commitment, adequate funding and flawless coordination among a wide-range of partners, Yemen achieved the target set out in the Global Vaccine Action Plan (GVAP) to reach 90% of children with the measles-rubella vaccine.

Problem is campaigns like this are an example of isolated improvements in reaching the nearly 1 in 5 children missing out on life-saving immunizations. Many countries are still way off-track. In order to reach every child by 2020, isolated improvements, including those to strengthen routine immunization, need to become the norm.

So, how do we get back on track?

Reducing missed opportunities, increasing coverage
WHO’s Strategic Advisory Group of Experts on immunizations (SAGE) met in October to review progress on achieving the GVAP targets, and reported most countries are still missing countless opportunities to protect children.

While substantial progress has been made in vaccinating 90% of children with the first dose of diphtheria-tetanus-pertussis (DTP) containing vaccine globally, many children do not come back for their second and third doses. Drop-out will need to be reduced if we are to achieve 90% coverage in 194 countries by 2015. In 2014, only 129 countries had reached this target.

One way of reducing drop-out is ensuring health workers always check vaccination cards when children are seen for well-child care or sick visits. Exit interviews conducted at health facilities in Chad and Malawi this year found 75% of children did not receive the vaccines for which they were eligible. Checking vaccination cards at every visit is an easy way of improving global vaccination coverage. We already have the child and his or her caregiver’s attention, so let’s make sure children have all of their vaccinations before they leave the clinic.

Most unvaccinated infants in the world remain located in a few large under-performing countries. With better data at national and especially at the subnational levels countries could assess pockets of under-immunization, identify exactly where missed opportunities exist and target these populations with localized solutions.

Common factors for success
Although opportunities were missed to reach every child last year, many countries had great success.

India, the second largest country in the world, was validated as having eliminated maternal and neonatal tetanus because it committed to improving access to immunization, antenatal care services and skilled birth attendance in the most vulnerable populations. It also improved coverage of the diphtheria-tetanus-pertussis-containing vaccines (DTP3) to 83%.

The Americas became the first region to eliminate rubella and congenital rubella syndrome, a major achievement.

Nigeria was removed from the list of polio-endemic countries in September, leaving the African Region one-step closer to being certified polio-free.

The key to success in all 3 of these examples was leadership and accountability at all 3 levels – national, regional and global. When countries and partners establish and enforce clear accountability systems, measure results, and take action when results are not being achieved, amazing progress will be made.

SAGE also identified an additional 5 factors to achieving significant results: quality and use of data; community involvement; better access to immunization services for marginalized and displaced populations; strong health systems and access to vaccines in all places at all times. While there is no one-size-fits-all solution to reach every child, we need to work with countries to understand how each of these success factors can help achieve a world free of vaccine-preventable diseases.

Reaching everyone throughout life
Going forward, countries should have annual plans for immunization that are consistent with the GVAP and relevant regional vaccine action plans. SAGE says it is not enough to just have a plan, countries need to strengthen the quality of their data, be accountable to their targets, and be monitored through an independent body.

Development partners, both global and national, cannot continue to be fragmented. We need to improve coordination and confirm our actions follow country and regional action plans. Vaccine stockpiles for humanitarian emergencies also need to continue to be replenished so that the second they are needed, they are available.

There is demand for immunization across the world. Now, we need to continue to meet the demand and reach every person with live-saving immunizations.

As we launch “Close the Immunization Gap”, the theme for next year’s World Immunization Week, let’s guarantee impressive gains achieved in some countries become the norm in all countries, and provide immunization for all throughout life.