Field Note

Vaccinating the World's Children: A Public Health "Best Buy"

Robert Steinglass
Technical Director
IMMUNIZATIONBasics (JSI, Inc.)

The lights in the concert hall are dimmed. One of the most popular rock and roll legends of the day comes onto the stage and the young audience grows wild with excitement. As the band launches into their box office hit - about infectious diseases of childhood - the audience sings along. In concert halls 50 years ago throughout the U.S., The Coasters entertained fans with the Lieber/Stoller lyrics to "Poison Ivy:"

"Measles will make you bumpy
Mumps will make you lumpy
And chicken pox will make you jump and twitch.

The common cold will fool you
And whooping cough will cool ["kill"(slang)] you
But Lord, poison ivy will make you itch."

Unpreventable 50 years ago, many infectious childhood diseases were very much in the public's mind and expressed in the culture. Who would have guessed then that vaccines against all but the common cold and poison ivy were imminent? In the U.S. alone, measles afflicted more than half a million children in some years with many deaths. Just before development of a vaccine in 1955, polio epidemics led to widespread public fear and the closing of swimming pools, summer camps and theaters. Photos of young children permanently encased in "iron lungs" to mechanically assist their breathing were a grim reminder of polio's lingering toll. Since then, the U.S. has seen 95 percent to 100 percent reductions in most vaccine-preventable childhood diseases through widespread vaccination.

Vaccines are considered to be among the greatest public health tools ever developed. A global initiative starting in 1967 succeeded in eradicating smallpox by 1980, saving approximately 2 million lives each year since then. Despite some recent setbacks, the global eradication of polio is anticipated within the next few years.

Early and full vaccination permits an infant to get a good start in life and dramatically improves a child's chance of survival. The consequent reduction in child mortality in the developing world leads parents to choose to have smaller families.

Yet many diseases against which vaccines are currently available - such as measles, whooping cough (pertussis), polio, tuberculosis, tetanus, diphtheria, yellow fever, hepatitis B and Haemophilus influenzae type b - still cause havoc in developing countries. An Arabic proverb warns parents, "Don't count your children until they have had measles." But these infectious diseases no longer need to be a rite of passage. The global community has learned how to effectively and efficiently deliver affordable vaccination programs at scale.

We already know how to vaccinate children even in the most crowded urban slums, most impenetrable jungles, and most inaccessible mountain villages. A continuous supply of high-quality potent vaccine must be distributed to the right places and stored in the right quantities under the right temperature for the right amount of time. Staff must have the knowledge, skills, support and motivation to safely implement and monitor the program according to national policies and guidelines. If the services are available, accessible, reliable and friendly, we have learned that most people will use the vaccination services, as long as they know where and when to bring their children.

Through highly coordinated efforts starting in the late 1970's, global vaccination coverage among infants rose from less than 5 percent in developing countries to nearly 80 percent by 1990. However, the perception that the job was completed led to a lapse in global attention and the withdrawal of investment. Coverage stagnated throughout the 1990's and has only modestly increased in the past few years. Wide coverage disparities remain both within and between countries and regions. One in four children in Southeast Asia and two in five children in Africa continue to be unprotected by existing vaccines against some of the most dangerous diseases of childhood.

At current levels of vaccination coverage, WHO estimates that about 3 million child deaths are prevented annually. Vaccination services must remain strong if that previous level of accomplishment is to continue. But wider and more equitable use of existing vaccines could additionally prevent approximately 2 million child deaths per year. In addition, widespread vaccination of today and tomorrow's children with the existing vaccine against hepatitis B will prevent nearly 1 million adult deaths each year in the future. New vaccines against pneumonia, rotavirus and meningitis, expected to be available for use in developing countries within a few years, will prevent another 1 million or more child deaths each year. And the vaccines of the future - e.g., against HIV/AIDS and malaria - will save millions of lives. However, the promise of existing and future vaccines cannot be realized without the leadership and investment of industrialized countries to keep the world's vaccination programs strong.

Vaccination is a bargain in every country. Not only does it prevent mortality, morbidity and disability, but it also leads to financial savings. The cost of treating diseases greatly exceeds the cost of prevention. An examination of the results of many cost-benefit studies related to vaccination in the U.S. validates the adage that "an ounce of prevention is worth a pound of cure." Roughly for every $1 spent on vaccination, about $10 to $20 is ultimately saved, depending on the disease, through reduced treatment costs and lost wages. Vaccination remains a most cost-effective intervention, leading to an annual $9 billion of savings in the U.S.

There has Been Renewed Interest and Additional Resources
The Global Alliance for Vaccines and Immunization (GAVI) was formed in 2000 as a public-private, performance-based partnership to introduce new and underutilized vaccines into developing countries and strengthen vaccination services, including safer injection practices. Second only to the Bill & Melinda Gates Foundation, the U.S. is the largest contributor to the Vaccine Fund, the financial arm of GAVI. Just last August, a pioneering $4 billion International Finance Facility for Immunization (IFFIm) was created by the European Community, at the urging of the United Kingdom and with financial support from France, Sweden and the UK. The IFFIm will enable countries to obtain funds from the international bond market for their vaccination programs. The expected $4 billion IFFIm investment over 10 years is expected to prevent the deaths of more than 5 million children and 5 million adults. If resources are invested in GAVI at their current level, an additional 1.5 million lives will be saved.

As an essential cost-effective public good that attracts little private sector support at the country level in developing countries, vaccination programs require deliberate public sector and donor investment to deliver services to all segments of the population. U.S. leadership historically has been critical for generating the resources and applying technical expertise to support developing countries to lower mortality and disability from vaccine-preventable diseases. The U.S. Agency for International Development (USAID) financially and technically supports national, multi-lateral, bilateral and NGO efforts to strengthen vaccination programs and achieve public health impact at scale. The U.S. Centers for Disease Control and Prevention (CDC) supports disease-specific initiatives against polio and measles and the strengthening of disease surveillance. In recent years, however, U.S. foreign assistance for child survival has not kept pace with the need nor with the expanding numbers of children who require protection. Increased leadership from the U.S. and additional secure funding would instantly be put to good use.

A strong vaccination program benefits other public health services. The cross-cutting systems developed for vaccination, including logistics, health information, monitoring, surveillance and communications, are used to support primary health care in general. With more than 500 million contacts annually in developing countries, vaccination programs can be used to add other services (de-worming, vitamin A supplementation, etc.) in an integrated and convenient package.

Past performance is no guarantee of future success. Unless a routine service delivery system capable of vaccinating children in their first year of life is in place, polio eradication cannot be maintained, newborn and maternal tetanus cannot be eliminated, measles mortality cannot be reduced over the long term, and new vaccines cannot be introduced. Investments in human, financial, and material resources must continue to keep pace with the need. The job is never completed, as each year another 135 million children are born into the world. The sustained support of partners over the long haul - governments, health agencies, foundations, NGOs and the public - will be required to reduce vaccine-preventable disease, disability, and death for the babies of today and those of tomorrow.

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