The Lancet Infectious Diseases, Volume 9, Issue 12, Page 730, December 2009

Childhood vaccination and progress towards MDG4

Kathryn Senior

Agencies and individuals worldwide are continuing their efforts to vaccinate the world's children and their achievements are highlighted by State of the World's Vaccines and Immunization, a major report published recently by WHO, UNICEF, and The World Bank. “We have good news…”, announced Daisy Mafubelu, Assistant Director General of Family and Community Health at WHO (Geneva, Switzerland). “The number of children being vaccinated is now at an all time high—and we have the numbers to prove this.” In 2008, 106 million children received routine vaccinations for childhood killer infectious diseases including measles, whooping cough, tetanus, and polio, more children than have ever been vaccinated in a single year.

The not so good news is that 24 million children each year remain unvaccinated and 2 million of them die as a result. Delivery of vaccine in areas where the health service infrastructure is fragile or non-existent is highlighted by the report as a major hurdle to achieving Millennium Development Goal 4 (MDG4)—to reduce deaths in children under 5 years old to 4·3 million each year. Rakesh Nangia, Director of Strategy and Operations for the Human Development Network at the World Bank highlighted the situation in his own country of birth, India: “Of those 24 million children, 10 million are in India and 60% of those children live in four states”, he reported. The availability of vaccines is not the problem since some of the largest vaccine manufacturers are now based in India. “It's the delivery systems and a trained workforce to deliver the vaccines that are most desperately needed”, he said.

The long-term benefits of investing in delivery systems for traditional childhood vaccinations extend to other vaccines. “The delivery systems that have been developed worldwide to supply the polio vaccine, the measles vaccine and others involve the same infrastructure that will be used by many countries to deliver the H1N1 vaccine, for example”, pointed out Stephen Blount (Acting Director, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA). At the moment, it does not appear that resources are being taken from routine vaccination to support the delivery of the H1N1 vaccine, but the imminent introduction of the pneumococcal and rotavirus vaccines and future vaccines for dengue, malaria and even tuberculosis and HIV, will involve higher costs. “In the 1980s, childhood vaccination was around US$3—5 per head but by 2010, that will rise to US$18. With the pneumococcal and rotavirus vaccines added in, the cost for each child will be close to US$30”, commented Nangia.

Funding continues to be an issue although the 72 poorest countries will have access to US$25 billion expected from government, multilateral, and other sources. Providing the shortfall of around US$10 billion before 2015, the final target date for achieving MDG4, will be a major hurdle in the context of the global economic recession. “In some countries anticipated growth in official development assistance has, of necessity, now been frozen and, in others, is being cut and governments are looking at how they will distribute these cuts”, pointed out Helen Evans (GAVI Alliance, Geneva, Switzerland). There have been some strong commitments to maintaining levels but Evans stressed that the WHO report is a call to action: “There is so much more that we can do than just maintain and increase current immunisation rates in low-income countries. The introduction of new pneumococcal and rotavirus vaccines can save millions of more lives. GAVI is already seeing great demand for these vaccines by countries”, she said.

Although GAVI is supporting immunisation programmes in the 72 poorest countries, a further 35 low-income to middle-income countries are not eligible for GAVI funding. The international community needs to rise to the challenge of immunising 30 million children in countries where the average income per person per day is only US$2. “The best example—I think the only example—of a solution is the Pan America Health Organization (PAHO) Revolving Fund. This works very well and has simple inclusion criteria. At PDVI, we are already working towards using the fund for the future dengue vaccine in the Americas”, Harold Margolis (Pediatric Dengue Vaccine Initiative, Seoul, South Korea) told TLID. Unfortunately there is no such mechanism for Asia or Europe, so three of the BRIC countries—Russia, India, and China—cannot benefit.

Sustainability of what is being achieved is also crucial: vaccination is only effective if it is carried out year on year. “We must keep long term goals in mind, as well as short term and intermediate aims”, stressed Jon Kim Andrus (Chief of the Immunization Unit, PAHO, Washington, DC, USA). “We need a commitment by countries to implement vaccine laws that would sustain the immunisation programme and follow up the belief that immunisation is a childhood right”, he concluded.