Vaccines have been touted – and rightly so – as the most cost-effective health intervention after access to clean water. It is estimated by global health institutions that vaccines save at least three million lives every year. While tremendous progress has been made since the discovery of vaccines in the 19th century, significant coverage gaps persist and in many countries, a worrying trend of vaccine reluctance threatens to undo many of the achievements brought about by public immunization programs.
Global immunization goals
In 1974, the Expanded Programme on Immunization (EPI) was launched by the WHO, with the mission of promoting access to six essential vaccines – diphtheria, pertussis, tetanus, poliomyelitis, measles and tuberculosis – in all countries. In 1999, the Global Alliance for Vaccines and Immunization (GAVI) was actually created to extend the reach of the EPI. Today, the EPI sets different immunization goals for different regions based on their needs and in accordance with the Global Vaccine Action Plan (GVAP), a framework with the goal of promoting more equitable access to existing vaccines for all communities globally. The GVAP concluded in 2020.
There are two basic types of vaccines:
- Live attenuated vaccines, produced by modifying a disease-producing virus or bacterium in a laboratory
- Inactivated vaccines, which compose either whole or factions of either viruses or bacteria
A tale of two diseases: smallpox and polio
Fittingly as the disease that originally led to the discovery of vaccination, smallpox is the first and only disease to be eradicated in human history – and it was done entirely through vaccination, since no treatment or cure for smallpox exist, even today. In the 20th century, an estimated 300 million people around the world died from smallpox, which had a fatality rate of around 30 percent in unvaccinated individuals. Happily, the WHO declared smallpox eradicated in 1980.
The Global Polio Eradication Initiative began in 1988, eight years after. By 2016, there were only 42 recorded cases of polio in the entire world. Tragically, through a combination of factors, the disease seems to be bouncing back, most notably in Afghanistan and Pakistan, but increasingly also spreading across sub-Saharan Africa, Yemen, Malaysia and the Philippines. A major cause has been the lack of access to vaccines in Taliban-controlled areas of Afghanistan and Pakistan. However, another reason is actually due to the older versions of the oral polio vaccine, which used live viruses that could be shed through feces. As a result of poor sanitation, the virus was able to replicate, regain strength, and grow virulent, leading to many cases of so-called ‘vaccine-derived polio’. The COVID-19 pandemic has only compounded the problem since many countries halted mass immunization campaigns to avoid the spread of COVID-19.
Zero dose children
According to Etleva Kadilli, director of UNICEF’s Supply Division, around 14 million children in the world are still unreached by their efforts – “zero dose children”. It is estimated that around 60 percent of all children who did not receive basic immunization in 2018 live in ten countries: Angola, Brazil, the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Nigeria, Pakistan, the Philippines and Vietnam. As is evident, progress in vaccine coverage remains patchy, between and within countries.
Kadilli highlights some of the typical challenges of access and UNICEF’s responses:
- Awareness: UNICEF works with local communities and community leaders, including religious leaders, as well as families directly, to communicate the life-saving impact of vaccines. We also work with and train local health workers to administer the vaccines and deliver these public health messages.
- Distribution and access to hard-to-reach areas: For most of these ‘zero dose children’, there are significant inequities and inequalities within the society that hinder access to vaccines, for instance, if we look at migrant or refugee populations. This is why we also have to work with governments across all levels.
- Affordability: UNICEF invests in market-shaping efforts. Some vaccines are quite expensive. While lower income countries can benefit from negotiated pricing and development aid, we have seen that pricing may be prohibitive for middle- and upper-middle income countries, limiting access to these life-saving vaccines for children in these countries.
Despite the enormous public health and economic benefits vaccines have brought to humanity in the past two centuries, in recent years, a worrying anti-vaccination trend has surfaced. In January 2019, the WHO named vaccine hesitancy as one of the top ten global health threats.
This has had a marked effect on global health outcomes. For instance, four European countries (United Kingdom, Albania, Greece and the Czech Republic) recently lost their measles elimination status. In Europe, over 82,000 cases of measles were reported in 2018 – an 80-fold increase since 2014. While other factors like access issues and supply interruption also contributed, vaccine hesitancy has been identified as a major cause.
Measles resurgence in the Philippines was also attributable to a problematic launch of a dengue vaccine in the country. The vaccine was launched in the Philippines in April 2016 but in November 2017 – after over 830,000 children had received at least one dose of the vaccine – Sanofi announced it was relabelling the vaccine to restrict its use to only those that had already been exposed to the dengue virus. The reason was that after re-analyzing its trial results, the evidence suggested that dengue-naïve people could be at risk for more severe cases of dengue fever after receiving the vaccine. The national scandal that ensued led to a significant drop in vaccine confidence.
It is estimated that for every USD 1 invested in immunization, around USD 16-18 are saved in healthcare costs – and the net return including broader economic benefits could be as high as USD 44. On the flip side, today, nearly half of all diseases from infectious diseases occur with diseases for which no vaccine is available.
But it is clear that the road towards more equitable and affordable access to safer, better and more vaccines is not straightforward, and often, it seems to be a case of two steps forward, one step back. While enormous momentum has been generated in 2020 and continues to push forward the global vaccine sector in 2021, it is patently clear that the road ahead is long. The world may have sprinted towards a COVID-19 vaccine but the marathon extends far into the future when it comes to the multitude of diseases – infectious or otherwise – that continue to wait for a vaccine.
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