Make vaccination a reality for all children
"This will give mothers peace of mind."
"This will reduce my fear of my child dying of pneumonia."
"This will reduce the number of trips mothers make to the health center."
"This will save me money if my child doesn't get sick."
"We need this, bring it quickly!"
"This" is pneumococcal vaccine, and the speakers were mothers in Rwanda, giving their views on this new vaccine prior to its introduction there a year ago. Enthusiasm for a vaccine that helps protect against the most common cause of childhood mortality ran high. And with vaccine donated by the GAVI Alliance, cold chain equipment provided by USAID, and technical support from the USAID-funded IMMUNIZATIONbasics Project, Rwanda became the first country in Africa to introduce this vaccine.
The recent pledge of the Bill & Melinda Gates Foundation to donate $10 billion for immunization in the coming "decade of vaccines" is inspiring - a balance of generosity and public health pragmatism. Together with support from other partners, this funding will help enable the widespread introduction in poor countries of vaccines against diseases that still account for about one quarter of all under-five deaths. At the top of the list are vaccines against pneumonia, specifically pneumococcal and Hib vaccines, and against diarrhea, specifically rotavirus vaccine.
But one lesson learned over the years is that all vaccines, whether new or "traditional," are only as effective as the system that delivers them. It's not enough to get the vaccines to the national cold stores. Babies and women must be reached with potent vaccines in a timely, safe, effective and affordable way, before exposure to disease, and with high quality services, so that they'll want to return to complete all their doses. And that's where the challenges come in-as well as opportunities.
• Providing strong routine immunization services, day-in and day-out. Occasional mass vaccination campaigns can increase the epidemiologic impact of some vaccines and contribute to goals of eradicating or eliminating some diseases. But routine immunization is a cornerstone of most health systems - a public good in itself as well as a barometer of the ability of governments to serve their populations.
• Ensuring that new vaccines are compatible with the setting where they will be used. For example, bulky packaging of some new vaccines overwhelms the storage capacity of refrigerators, costs more money to transport, limits the number of doses that health workers can take to outreach sessions, and creates headaches -and increases costs-for health care waste management. While the impact of vaccine product presentation is felt in the field, it is at global levels that negotiations with vaccine manufacturers take place as to the specific characteristics of the product.
• Providing immunization services as efficiently as possible. Newer vaccines tend to be more expensive than older ones. This means that common management problems such as high drop-out rates take on greater significance if the vaccines are used incompletely so that children are not completely protected. And while reducing vaccine wastage rates is also of high concern, it must be balanced against the need to protect as many children as possible while assuring that the vaccine is used safely.
• Using the opportunity of vaccination visits to maximum benefit. In the child's first year of life, routine immunization affords five contacts with the health system. That's five times when the baby could be weighed or given vitamin A or otherwise assessed, or when the mother could be provided with family planning services or other care. Just as a strong routine immunization system can help support other services, so can those services provide a supportive platform for immunization.
As a program whose goal is to reach 100 percent of children born each year, immunization has developed approaches that lend themselves to adaptation by other health programs, as exemplified by the programmatic pathway to prevention.
Over the years, we've learned that, even after scaling up, the job isn't done. With maturity comes new challenges:
First, we can't become complacent. We can't take our past accomplishments for granted: past success is no guarantee of future success. Global immunization coverage, estimated at about 80 percent in 2008, was also at this level in 1990 before global health investment priorities shifted and immunization coverage dropped and stagnated. Second, we must reach the remaining underserved populations to improve effectiveness and equity. In Africa and south Asia, more than one quarter of children are not fully vaccinated. Third, we must innovate, first and foremost by introducing new vaccines to save another million lives per year. And we must constantly scan the horizon to identify opportunities and threats, make necessary adaptations, and seek continued investment.
As long as there are children are being born, there are children needing immunization. So we must implement sustainable services and make good on the full promise of this most equitable and effective of public health services.
Rebecca Fields is the senior technical advisor for global health, population and nutrition at the Academy for Educational Development. Robert Steinglass is the immunization team leader for the Maternal and Child Health Integrated Program (MCHIP)/JSI. Images courtesy of AED
This blog first appeared in Global Health Magazine’s blog.