Milestones :: Perspectives

Milestones :: Perspectives

Reaching everyone, everywhere with life-saving vaccines
Commentary
25 February 2017
Dr Margaret Chan, Director-General of WHO,
Chris Elias, President of the Global Development Program at the Bill & Melinda Gates Foundation,
Anthony Fauci, Director of the US National Institute of Allergies and Infectious Diseases,
Anthony Lake, Executive Director of UNICEF,
Seth Berkley, Chief Executive Officer of Gavi, the Vaccine Alliance

In 2015, world leaders agreed to a new development plan—a set of Sustainable Development Goals (SDGs). Expanding access to immunisation is crucial to achieving the SDGs.1, 2 Not only do vaccinations prevent the suffering and death associated with infectious diseases such as pneumonia, diarrhoea, whooping cough, measles, and polio, they also help enable national priorities like education and economic development to take hold.

The unique value of vaccines was the driving force behind the Decade of Vaccines, an effort launched at the 2010 World Economic Forum and supported by many stakeholders to extend the full benefits of immunisation to all by 2020.3 Governments welcomed the initiative, and 194 member states endorsed the Global Vaccine Action Plan (GVAP) at the 65th World Health Assembly.4 The plan is ambitious and aims to ensure that all people everywhere live free from vaccine-preventable diseases.

Since then, WHO’s Strategic Advisory Group of Experts (SAGE) on Immunization has issued annual progress reports. The 2016 GVAP midterm report5 provides a careful analysis of progress and challenges, and indicates that although there are bright spots in global immunisation efforts, the overall picture is sobering.

First, the bright spots. More children are being immunized worldwide than ever before with the highest level of routine coverage in history (as measured by coverage of three doses of the diphtheria-tetanus-pertussis (DTP)-containing vaccine).5 The world is closer than ever to eradicating polio. Since 2010, 99 low-income and middle-income countries have introduced one or more new or underused vaccines—for example, rotavirus and pneumococcal vaccines—exceeding the GVAP target for 2015.5 Indigenous measles and rubella have been eliminated from the Americas, and maternal and neonatal tetanus has been eliminated in southeast Asia.

Important progress has been made in vaccine research and development: a new vaccine against dengue has been licensed in several countries,5 and the first vaccine to protect children against malaria will be piloted in three African countries in 2018.7 In the past 2 years, there has been an increase in the number of vaccines in the clinical development pipeline.

The GVAP midterm report also reveals encouraging national and regional trends in vaccine coverage. For example, since 2010, 16 countries have substantially increased coverage of the third dose of the DTP vaccine, confirming that progress on immunization can be achieved with strong domestic leadership, meaningful investments, and effective accountability mechanisms.
Yet major challenges remain. All of the GVAP targets for disease elimination—including measles, rubella, and maternal and neonatal tetanus—are behind schedule. Although more infants than ever before are receiving the critical third dose of the DTP vaccine, global coverage of these basic vaccines has increased by only 1% since 2010.5 This slow progress puts one of the most important goals in the GVAP seriously off track.

Although inequalities in the implementation of vaccination programmes have narrowed in the past decade as the poorest and least educated people gained more coverage, gaps persist. Only 52 of 112 member states with available and valid district-level data have surpassed the district-level coverage target of 80%. A high priority must be placed on the equitable extension of vaccine coverage to all. Finally, while financial support and commitment from donors and countries has increased, reflecting a global commitment to immunization, this increase is insufficient to meet all the needs to realize the GVAP targets.

In almost every country, some population groups have limited access to vaccines. These groups include people living in poverty, those who live in remote rural locations, segments of the urban poor, and displaced and nomadic people. This problem is compounded by data deficiencies at the national and local levels, which makes it even more challenging to identify where gaps lie and what is causing them—and thus to take corrective action. Several countries also report that vaccine prices are a barrier to the introduction of vaccines into their national programmes.

Many health facilities still have insufficient resources to engage with communities and provide them with the comprehensive public health services they need. Failure to integrate service delivery mechanisms has decreased the opportunities for health workers to improve immunization coverage and other key interventions to improve people’s health. Conflict and public health emergencies, such as the outbreaks of Ebola virus disease and Zika virus, and outbreaks of vaccine-preventable diseases—for example, measles, yellow fever, and cholera—have strained fragile health systems.

Finally, inadequate domestic investments and continued donor dependency in many low-income and middle-income countries are raising concerns about the long-term global sustainability of immunization programmes, especially as funding for the polio programme slows down and countries transition away from the support they receive from Gavi, the Vaccine Alliance.
Where do we go from here? First, the global health community must continue working to provide all vaccines recommended by WHO to each and every child by ramping up efforts to extend full immunization to the about 19 million children who are still not fully protected against a core set of vaccine-preventable diseases. Efforts to build strong routine immunization systems, which balance supply and demand, must be intensified.

Routine immunization is a building block of strong primary health care and universal health coverage—it provides a point of contact for health care at the beginning of life and offers every child the chance of a healthy life from the start. Immunization is a cornerstone of global health security in an interconnected world where diseases do not respect national borders. Vaccines also serve as a frontline defense against antimicrobial resistance. Furthermore, a 2016 study showed that for every US dollar spent on childhood vaccinations, the return on investment is US$44 when the full range of economic benefits are considered—making immunization one of the most cost-effective health interventions.

In addition to implementation challenges, we still face substantial research challenges. Vaccines are lacking or sub-optimal for many serious infectious diseases that exact an enormous toll worldwide. To address this problem, it will be crucial to ensure that vaccine markets provide the right incentives to invest in research and development for these vaccines and to expand research and development capacity in low-income and middle-income countries.

The global health community must work together to advance progress. Although governments are the main providers of immunization, the GVAP’s success depends upon many stakeholders—families, communities, health professionals, civil society, development partners, global agencies, manufacturers, media, and the private sector. It is essential that governments show strong leadership and good governance of national immunization programmes, which involves prioritizing system strengthening, securing investments, and improving surveillance capacity and data quality and use. Organisations that deliver immunization programmes, research and development partners, as well as global agencies can help improve GVAP accountability, work to overcome barriers to the timely delivery of vaccines in humanitarian crisis, and support vaccine research and development in low-income and middle-income countries.

Delivering on the goals and the promise of the GVAP is an urgent and essential priority. It will improve the health and wellbeing of people everywhere and help us achieve the SDGs, and ultimately a world in which no one—no child, no adolescent, no adult—is left behind. In 2017, we challenge countries and our own organisations to do more.

[Link to The Lancet version: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30554-8/fulltext?rss=yes ]