#VaccinesWork… don’t they?

Lancet Global Health
May 2018 Volume 6 Number 5 e469-e592

#VaccinesWork… don’t they?
The Lancet Global Health
One hundred years ago in April 1918, as American soldiers landed on European soil in the final months of World War I, so did a virus detected a month earlier at an army training facility in Kansas, USA, accelerating what would be the first wave of the 1918 flu pandemic. The exact origin of the pandemic is not known, but the culprit is: it was an influenza A(H1N1) virus, the kind that would again emerge and spread worldwide in 2009, causing this time a reported (and probably underestimated) 19 000 deaths. Global health has come a long way since then: the development of influenza vaccines, including a potentially universal one granting protection against all flu strains, and preparation for pandemic influenza are now integral parts of health and security efforts. Yet 100 years later, influenza prevention is not free of debate and controversy, and neither is the field of vaccines and immunisation.

Vaccination has contributed tremendously to global health. Since the creation of the Expanded Programme on Immunization in 1974, it has saved countless lives and improved the living conditions of millions of people. So as we near the end of the Decade of Vaccines, with its promise of universal access to immunization by 2020 via the Global Vaccine Action Plan (GVAP), it seems almost paradoxical that global coverage of such a successful and cost-effective tool is showing only sluggish progress. Results of the 2017 report from WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) on implementation of the GVAP were concerning, as slow improvement in vaccination coverage, misalignment of strategies and funding, and external threats to progress were evoked. SAGE will meet this April as part of its twice-yearly schedule and while there may be some progress to celebrate, pressures on vaccination efforts will certainly continue to permeate the discussions.

Conflicts, instability, and humanitarian disasters are especially challenging and disrupt efforts to reach those most in need of vaccines. Examples abound in today’s geopolitical state of affairs and among the most heart-wrenching is the situation of the Rohingyas stranded in Cox’s Bazaar and Bandarban, Bangladesh, where as Delan Devakumar describes in a Comment in this issue, the risks of the monsoon season are coupled with outbreaks of measles and diphtheria. In east Ghouta, in spite of an emergency vaccination campaign against measles, rubella, tuberculosis, hepatitis, and polio, Syrian refugees remain vulnerable to diseases. Weakened health systems such as Venezuela’s are susceptible to resurgence of diseases that threaten decade-long regional efforts, such as measles elimination in the Americas. Venezuela also shares a border with Brazil, where a high risk of urban yellow fever transmission has prompted a nationwide vaccination campaign.

Another impediment to progress is true political commitment to an issue that has complex budgetary implications, particularly in countries where economic progress is such that they are transitioning out of international financial assistance. One example is Nigeria, which, following rebasing, qualifies out of GAVI in spite of paltry immunisation coverage indicators and the continuing threat of polio. In this case, GAVI’s board has agreed to an exceptional support plan beyond 2020, and Bill Gates announced in March that he would support the country’s immunisation efforts by paying up a US$76 million loan from Japan. The question is whether ad-hoc interventions of this type would be repeated with other transitioning countries.

Vaccination efforts are also clearly aligned with the Universal Health Coverage (UHC) agenda, but financing and service delivery plans on the road to UHC might affect the way immunisation programmes and services are prioritised, adding uncertainty. Beyond budgetary considerations, vaccine policies must strike the right balance between imposing vaccination or giving a choice, to parents in particular, in environments where vaccine skepticism can be high. Recent laws making several childhood vaccines mandatory in France and Italy have generated much debate and highlighted the reality that the power of vaccines can be threatened in countries on the full spectrum of national incomes, and not only where lack of access is due to lack of resources.

There is no doubt that vaccines work: they save lives, they are the best investment a country could make for its citizens. Yet immunisation only really works when all the pressures on coverage, those mentioned above and many more, are relieved in a collective effort. The theme of this year’s World Immunization Week on April 24–30, “Protected Together, #VaccinesWork” is a good reminder of that.