Milestones :: Perspectives

Milestones :: Perspectives

Editor’s Note:
We lead this “Milestones” section with the overview and commentary from most recent WHO and UNICEF immunization estimates. In the context of the aspirations of GVAP now past mid-point – and in principle – the numbers of un-vaccinated and under-vaccinated children should alarm us all.

1 in 10 infants worldwide did not receive any vaccinations in 2016
Joint news release UNICEF/WHO
GENEVA/NEW YORK, 17 JULY 2017  ─ Worldwide, 12.9 million infants, nearly 1 in 10, did not receive any vaccinations in 2016, according to the most recent WHO and UNICEF immunization estimates. This means, critically, that these infants missed the first dose of diphtheria-tetanus-pertussis (DTP)-containing vaccine, putting them at serious risk of these potentially fatal diseases.

Additionally, an estimated 6.6 million infants who did receive their first dose of DTP-containing vaccine did not complete the full, three dose DTP immunization series in 2016. Since 2010, the percentage of children who received their full course of routine immunizations has stalled at 86% (116.5 million infants), with no significant changes in any countries or regions during the past year. This falls short of the global immunization coverage target of 90%.

“Most of the children that remain un-immunized are the same ones missed by health systems,” says Dr Jean-Marie Okwo-Bele, Director of Immunization, Vaccines and Biologicals at WHO. “These children most likely have also not received any of the other basic health services. If we are to raise the bar on global immunization coverage, health services must reach the unreached. Every contact with the health system must be seen as an opportunity to immunize.”

Immunization currently prevents between 2-3 million deaths every year, from diphtheria, tetanus, whooping cough and measles. It is one of the most successful and cost-effective public health interventions.

Global immunization coverage levels
According to the new data, 130 of the 194 WHO Member States have achieved and sustained at least 90% coverage for DTP3 at the national level – one of the targets set out in the Global Vaccine Action Plan. However, an estimated 10 million additional infants need to be vaccinated in 64 countries, if all countries are to achieve at least 90% coverage. Of these children, 7.3 million live in fragile or humanitarian settings, including countries affected by conflict. 4 million of them also live in just three countries – Afghanistan, Nigeria and Pakistan – where access to routine immunization services is critical to achieving and sustaining polio eradication.

In 2016, eight countries had less than 50% coverage with DTP3 in 2016, including Central African Republic, Chad, Equatorial Guinea, Nigeria, Somalia, South Sudan, Syrian Arab Republic and Ukraine.

Globally, 85% of children have been vaccinated with the first dose of measles vaccine by their first birthday through routine health services, and 64% with a second dose. Nevertheless, coverage levels remain well short of those required to prevent outbreaks, avert preventable deaths and achieve regional measles elimination goals…

152 countries now use rubella vaccines and global coverage increased from 35% in 2010 to 47% in 2016. This is a big step towards reducing the occurrence of congenital rubella syndrome, a devastating condition that results in hearing impairment, congenital heart defects and blindness, among other life-long disabilities.

Global coverage of more recently-recommended vaccines are yet to reach 50%. These vaccines include vaccines against major killers of children such as rotavirus, a disease that causes severe childhood diarrhoea, and pneumonia. Vaccination against both these diseases has the potential to substantially reduce deaths of children under 5 years of age, a target of the Sustainable Development Goals.
Many middle-income countries are lagging behind in the introduction of these newer and more expensive vaccines. These countries often do not receive external support and their health budgets are often insufficient to cover the costs of procuring these vaccines.

Inequities in immunization coverage
National coverage estimates often mask large inequities in coverage within countries. The WHO report, State of inequality: Childhood immunization, highlights inequalities in childhood immunization coverage in low- and middle-income countries over the past 10 years. The report shows that global improvements have been realized with variable patterns of change across countries and that there is generally less inequality now than 10 years ago.

These findings were reinforced by a recent UNICEF study, which emphasized the cost effectiveness of investing in the poorest, most marginalized communities.

“Immunization is one of the most pro-equity interventions around,” says Dr Robin Nandy, Chief of Immunizations at UNICEF. “Bringing life-saving vaccines to the poorest communities, women and children must be considered a top priority in all contexts.”

Efforts to reduce inequalities related to household economic status and mother’s education are needed in many countries if immunization coverage is to be improved. Additionally, more than half of the global population resides in urban areas, including in rapidly growing slums in Africa and Asia. The urban poor is a group at high risk of being un- or under-immunized.

For the first time, WHO and UNICEF have collected disaggregated data on immunization coverage at the subnational level. Of 194 reporting countries, 125 reported on subnational coverage, covering nearly 20 000 districts and roughly two–thirds of the global infant population. These data will help shed more light on geographical disparities in access to vaccines.
Gavi [to 22 July 2017]
Vaccine progress in developing countries ‘in danger of stalling’
New figures show an increase in measles, pneumococcal and rotavirus vaccine coverage in developing countries, but basic vaccine coverage remains unchanged at 80%

Geneva, 20 July 2017 – “The extraordinary improvement in immunisation coverage made since 2000 is in danger of stalling, with conflict, human and animal migration, urbanisation and vaccine hesitancy adding new barriers to global vaccination efforts,” Dr Seth Berkley, CEO of Gavi, the Vaccine Alliance, said today.

New WHO/UNICEF figures released this week show that in 68 of the world’s poorest countries, while close to a million more children received the basic diphtheria-tetanus-pertussis vaccine in 2016 compared to 2015, the coverage rate has remained at 80% for the past three years. Millions of children remain under-vaccinated in countries torn apart by conflict, from Syria to South Sudan.

“Since 2000 an unprecedented international effort to improve immunisation in the world’s poorest countries has helped to save millions of children from killer diseases like measles, tetanus and whooping cough,” said Dr Berkley. “Thanks to vaccines more children are now living to see their fifth birthday than at any point in history.”

“However, while these figures need to verified by detailed country surveys, they appear to show that this extraordinary progress is in danger of stalling,” he said. “Growing trends like human and animal migration, urbanisation and vaccine hesitancy, as well as conflict, are combining to make the challenge of reaching every child even tougher. The fact that Nigeria has overtaken India as the country with the greatest number of under-vaccinated children, despite having less than a seventh of the population, is particularly concerning. We now need to work twice as hard to meet these challenges and ensure no child goes without lifesaving vaccines.”

“There are positives we can take from this data,” said Dr Berkley. “Newer vaccines protecting against the leading causes of pneumonia and diarrhoea are reaching millions more children across Africa. Liberia’s health system is recovering after the damage wrought by Ebola and India’s commitment to routine immunisation is also continuing to pay dividends.”

In the 68 countries supported by Gavi an additional 5.4 million infants received their second dose of measles vaccine in 2016, 4.8 million more children were vaccinated against the leading cause of pneumonia and 2.3 million more were vaccinated against rotavirus, the leading cause of severe diarrhoea.

The WHO and UNICEF Estimates of National Immunisation Coverage 2016 (WUENIC 2016) figures show that:
:: 19.5 million infants globally did not receive all three doses of diphtheria-tetanus-pertussis (DTP3) vaccine.
:: DTP3 coverage in Liberia increased to 79% from just 52% in 2015, while coverage in India edged up to 88% from 58% in 2000.
:: Nigeria has overtaken India as the country with the greatest number of under-vaccinated children, with 3.4 million children missing out on DTP3 compared to 2.9 million in India.
:: In 2016 coverage of Haemophilus influenzae type b (Hib), pneumococcal and measles vaccines for the 68 countries in which Gavi works increased markedly. Coverage of children receiving three doses of Hib rose from 67% to 78%, pneumococcal from 35% to 41%, and the second dose of measles vaccine from 43% to 50%.
:: One-quarter of infants in Gavi-supported countries are now protected against rotavirus, one of the leading causes of diarrhoea, with supported vaccines.
:: The difference in DTP3 coverage between Gavi-supported and high-income countries is now half of what it was in 2000 (2000: 33%, 2016: 16%)…
IMPUNITY MUST END: Attacks on Health in 23 Countries in Conflict in 2016
July 2017 :: 84 pages
This report should once again serve as an alarm about the scale and scope of attacks on health
care. In many cases, these violations amount to war crimes and crimes against humanity, and
collectively they threaten the health, well-being, and the lives of people who may number in the
millions. In 2016, these attacks continue to occur with impunity.

Excerpt from Introduction
This is the fourth annual report by the Safeguarding Health in Conflict Coalition documenting attacks on, interference with, and obstruction of health workers, patients, facilities, and transports during periods of armed conflict and political violence across the world. The Safeguarding Health in Conflict Coalition is a group of more than 30 civil society, health provider, and human rights organizations working to protect health workers and services  threatened by war or civil unrest. We have raised awareness of global attacks on health and pressed United Nations agencies for greater global action to protect the security of healthcare. We monitor attacks, strengthen universal norms of respect for the right to health, and demand accountability for perpetrators.
In this report, we review events in 23 countries affected by conflict or political volatility in 2016, compared to 19 countries in 2015. The countries we are reporting for the first time are Armenia, Egypt, Ethiopia, Jammu and Kashmir (India), Mozambique, and Niger. Two countries that were included in our 2015 report—Colombia and Thailand—are not included in this report because either there were no reported attacks or sound data were not available.

Excerpt from Executive Summary [p.10]
Community health workers often work tirelessly to deliver medications and vaccinations to ensure equitable access to health care and to protect groups from communicable diseases, especially polio. Their provision of services in communities often places them at high risk and they have been subject to targeted killings and abductions in Afghanistan, Nigeria, and Nigeria.  In recent years, under pressure to eradicate polio, Pakistan has increased police protection for vaccinators. The increased security has saved the lives of many vaccinators and has enabled children to receive the vaccinations they need, but it has also resulted in the targeting and killing of police and armed forces charged with providing security for vaccinators.

In Afghanistan, in 13 recorded attacks, 16 vaccinators were abducted and ten killed. Some armed opposition groups have reached agreements with the government to allow vaccination efforts to continue. However, other groups have demanded a halt to vaccination campaigns, abducted and killed vaccinators, and destroyed stores of vaccines.

In Pakistan, attacks on polio workers and police took place in January, March, April, May, September, and October. In the January attack, 15 people were killed at a vaccination center; in April, seven police providing security for vaccinators were killed. Physicians supervising the vaccine campaigns and police protecting community health workers were shot and killed.

In Nigeria, four polio workers were kidnapped and held for ransom, jeopardizing the progress made towards polio eradication. This type of intimidation represents one of the factors that contributed to an outbreak of the disease in the country for the first time in more than two years.