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Friday, August 1st, 2014

Childhood vaccinations peak in 2009, but uneven distribution persists

By Sakina Shakil


A young girl receiving measles vaccination shots in the Central African Republic.

While the news that childhood vaccinations reached an unprecedented high in 2009 seemed to be solid progress towards achievement of the fourth UN Millennium Development Goal (MDG), which calls for a two-thirds reduction in child mortality rates by 2015, it was also announced on 21 October by international organisations that the worldwide distribution of childhood vaccines was inequitable.

The State of the World’s Vaccines and Immunization, a report jointly released by the World Health Organization (WHO), the UN Children’s Fund (UNICEF), and the World Bank, concluded that despite child vaccinations hitting a record-high with about 106 million infants being immunised this year, life-saving vaccines fail to reach some 24 million children in 72 of the world’s poorest countries. These children are estimated to be most at risk from vaccine-preventable diseases. The report declared vaccinations, with the exception of safe water, as being the greatest factor in mortality reduction: “The stakes are high. WHO has estimated that if all the vaccines now available against childhood diseased were widely adopted, and if countries could raise vaccine coverage to a global average of 90 per cent by 2015, an additional 2 million deaths a year could be prevented among children under 5 years old.”

Successes achieved, but other problems remain

UN agencies have called for an additional US$1 billion per year, estimating that this is the minimum amount needed to ensure new and existing vaccines will reach and be administered to children in the world’s poorest countries. According to Maxim News Network, UNICEF Executive Director Ann M. Veneman said the need of additional funding for vaccinations was essential to progress: “Worldwide measles deaths fell by 74 per cent between 2000 and 2007, and vaccinations played an important part in that decline. Such progress must inspire new efforts to immunise children around the globe against life-threatening diseases."

The past year has seen its fair share of successes in immunisation campaigns, achieved mainly because of financial stability or support. In the United States, one of the world’s richer nations, 81 per cent of toddlers received the full, recommended series of vaccinations in 2009, according to the US Center for Disease Control and Prevention. Immunisation campaigns were successful in smaller countries like Tajikistan, where, in October 2009, 97 per cent of children below 14 years of age received vaccinations against measles and rubella by Tajikistan’s health ministry, with financial support from UNICEF and the WHO.

However, other issues also need to be addressed to achieve equitable vaccination distribution. The aforementioned report acknowledges that many children in the world’s poorest countries are difficult to reach. Some children live in remote rural areas, deprived urban settings, politically fragile states, or war-torn regions; progress still needs to be made in order for vaccination programmes to reach them. Moreover, according to Reuters, middle-income families in developing countries are often not eligible for financial assistance in health services, making it difficult for them to afford newer vaccines.

Additionally, in developing countries where vaccination programmes are implemented, questions about safety have been raised. In Gauteng, South Africa, where a measles vaccination programme was launched this October, BuaNews reported concerns by parents that the same needles were being used for multiple shots, exposing children to other possible diseases and infections. Questions about the vaccine itself were also raised. The Department of Health responded by assuring parents there was no truth to claims regarding the needle concerns, and that the vaccination programmes were the only safe way to fight against measles and other diseases.

Similair concerns were raised in India after the Times of India reported a 3-month-old baby died at Kambainallur village, in the state of Tamil Nadu, ten days after receiving the combined shot for diphtheria, tetanus, and pertussis (DTP) and a shot for Hepatitis B. According to the US Food and Administration (FDA), the pertussis component of DTP shots causes more adverse reactions than any other vaccine, such as a high fever and convulsions, and exceptional care should be taken into the construction of DTP shots. Informanté.com says that most developed countries, including the United States, the United Kingdom, and France, have replaced the DTP vaccine with the more secure DTaP vaccine, but the higher cost of DTaP is the main reason developing countries have not done the same. The nurse who had administered the DTP shot in Kambainallur told the Times of India that she had given the same batch of the vaccine to nine other children, and “none of them had any problem.”

Though further details about this situation were not released, infant deaths related to the DTP vaccine have been investigated in Namibia as well. Informanté.com reported in February 2009, a 6-week-old baby died less than 24 hours after receiving a DTP vaccination shot in Windhoek; the cause of death was determined to be brain damage.

Vaccine-related deaths have also been reported before in Tamil Nadu. According to thaindian.com, in April 2008, five infants died following the administration of a measles vaccine; as a result, the Central Health Minister Anbumani Ramadoss cancelled all vaccination shots and ordered an investigation. The state and central government concluded that no negligence had taken place on the part of health workers, as thousands of children had received the vaccine on the same day without complications, but controversy over the safety of the vaccinations remains.

US$1 billion needed

The State of the World’s Vaccines and Immunization report recognizes the GAVI Alliance, a global vaccine-financing partnership, as being a key element to the successes made in vaccine distribution so far, and believes the organisation’s work in securing funding for immunisation campaigns will lead to progress in achieving equitable vaccine distribution worldwide.

The GAVI Alliance incorporates both public and private organisations – including the WHO, UNICEF, the World Bank, and the Bill and Melinda Gates Foundation – as stakeholders in immunization programmes, acknowledging that the challenges ahead in achieving worldwide equitable child immunization are difficult but surmountable with combined international efforts. According to the GAVI Alliance, nearly 2.3 million children continue to die every year from vaccine-preventable diseases, even amidst dropping child mortality rates. GAVI Alliance CEO, Dr Julian Lob-Levyt, called this unacceptable: “The demand by low-income countries for new, life-saving vaccines has never been higher. We must answer their call.” The plea for international donations amounting to US$1 billion was also made by the GAVI Alliance for the international pursuit of equitable vaccine distribution in low-income countries.

UN agency UNITAID responded to the plea with the creation of an airline ticket programme, which allows airline customers to voluntarily contribute US$2 to help fight HIV/AIDS, malaria, and tuberculosis each time they purchase a ticket. The initial participatory companies include Amadeus, Travelport, and Sabre Holding Corporation, and the donation recipients include UNICEF and the William J. Clinton Foundation, the latter of which is a charitable foundation established by former US president Bill Clinton. The programme is set to begin in January 2010, and will include participation from countries such as the United States, Britain, Germany, Spain, and Switzerland. Projected numbers indicate that the airline ticket programme has the potential to raise US$1 billion in 4 years, with only 5% of the funds collected going towards administrative expenses.

The GAVI Alliance and 2009 successes

In securing financing from a variety of donors, GAVI Alliance has made it possible for some developing countries to pursue immunisation campaigns this year. According to Reuters, Rwanda announced in April plans to immunise about 395,000 infants for pneumonococcal disease by the end of 2009. Pneumonococcal disease is amongst the world’s leading vaccine-preventable diseases, but still claims 1.6 million lives each year, with nine out of 10 deaths occurring in developing countries. Rwanda, the first developing nation to introduce vaccination for the disease, was able to do so through donations from pharmaceutical giant Wyeth and support from the US Agency for International Development. A similar programme in Gambia was implemented in June 2009 by the GAVI alliance, which had organised the Rwandan vaccination programme. The GAVI alliance also organised an immunisation campaign for India in August, where a US$165 million grant from the Indian government, WHO, UNICEF, the Hib Initiative, and other private donors made it possible for over 18 million children to receive the pentavalent (five-in-one) vaccine, which protects against diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b (Hib), the latter of which can lead to severe forms of pneumonia and meningitis.

The GAVI alliance pursues monetary grants to administer vaccination programmes in countries that cannot afford them on their own, and this pursuit has been easier recently, primarily because of the rapid growth of the global vaccine market. According to the report, the global vaccine market has tripled over the last eight years and pulls in over US$17 billion in revenue, largely due to the rising demand of UN agencies and what has been called a “renaissance” in vaccine discovery and development. According to the UN News Centre, World Bank Director Graeme Wheeler believes that new developments in vaccine research and production are an essential step towards reaching the fourth MDG if they can be applied equitably to vaccination programmes worldwide: “We have seen a dramatic turnaround in the availability of vaccines in even the poorest countries. Yet the international community, together with the countries themselves, must ensure that new and existing technologies actually reach the most vulnerable populations, especially children.”

Technological development

The Bill and Melinda Gates Foundation, a philanthropic organisation targeting global health problems, funds technological development as a progressive method to combat health crises. On 20 October, the Foundation announced that its Grand Challenges Explorations programme would award 76 grants, each one around US$100,000, to pursue bold ideas for transforming health in developing countries. Launched in 2008, Grand Challenges Explorations is a five-year, US$100 million initiative promoting innovation in global health. Dr Tachi Yamada, president of the foundation’s Global Health Program, said, “Grand Challenges Explorations will continue to fill the pipeline with possibilities and hopefully produce a breakthrough idea that could save untold numbers of lives.”

A McGill University study also believes that technological progress can be effective in ensuring vaccine distribution in poorer countries, but it should move in a more organic direction to do so. The study, titled A Model of Regulatory Burden in Technology Diffusion: The Case of Plant-Derived Vaccines [PDV], concluded that PDVs would be a more cost-effective and safer method for vaccination programmes to adopt. PDVs are vaccines in which plants are grown and processed, and the final product is dosed for oral administration rather than injection, eliminating the risks association with needles. Other benefits of PDVs are that they involve lower production costs and do not require temperature control for storage and distribution. However, they currently exist in only a research stage and for clinical testing, and it would take time to establish and prove their safety and effectiveness for public use.

Improving current programmes and alternatives

While financial support and technological advancement are needed, others believe that existing immunisation programmes in developing countries are what need to be improved. Indian Health Minister Ghulam Nabi Azad told the Times of India that despite having vaccination programmes, the country still had not made tangible improvements in the eradication of vaccine-preventable diseases: “Why is it that despite high … coverage, we are failing to eradicate diseases like polio? We have to start double checking immunisation numbers being given to us by states.” According to the Indian Health Ministry, there was a gap between reported and actual coverage, and while government agencies were reporting high immunization rates in areas like Bihar and Rajasthan, independent organisations were showing much less coverage. The solution proposed by Mr Azad was a comprehensive data programme that would record the name of the child vaccinated, the child’s father’s name, the village and neighborhood they came from, which city they belonged to, and phone numbers of the child’s family or neighbors. The Indian Health Ministry concluded that the more information recorded, the easier it would be to pinpoint which children have not been vaccinated.

Alternatives to vaccination shots are also being introduced. In 2006, the Nothing but Nets campaign, a grassroots movement that distributes bed nets throughout Africa with the aim of preventing malaria, was launched. The campaign works with the Measles Initiative – a partnership of the American Red Cross the US Centers for Disease Control and Prevention, the UN Foundation, the WHO, and UNICEF. In the first year of the campaign, almost 20 million bed nets were distributed in 10 African countries, such as Ethiopia, Kenya, and Nigeria.

Thus, injection-alternative campaigns and improvements upon current vaccination programs are important strategies that can make valuable contributions to evening out the worldwide distribution of vaccines, but it seems that financial support for immunisation campaigns in low-income countries is a more popular initiative. Either way, international commitment to financially backing immunization initiatives is critical in order to reach the MDG of decreasing child mortality rates by two-thirds by 2015. The world’s poorest countries house children who are most at risk of vaccine-preventable diseases, and as WHO Director-General Margaret Chan said after the report’s launch, “We must overcome the divide that separates rich from poor – between those who get life-saving vaccines, and those who don’t.”