Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
Please can you give an outline of the current state of immunization around the world?
Overall, worldwide, immunization programs reach around 83% of all children – this is an enormous achievement.
With this level of immunization coverage, we prevent over 2 million deaths, year after year. This statistic is often forgotten or taken for granted.
We are able to reach 83% of children because immunization systems basically have the widest reach of all public health
programmes in most countries, and is the result of hard work over the last two to three decades.
The flip side of having an 83% coverage is that some 17% of kids do not get immunized - that's one out of five children.
That “5th child” who doesn’t get immunized, is the same one who doesn’t have access to other health services; who is the most vulnerable; for example, the children who belong to a minority or who live in remote areas or in slums.
The same kids who don't get immunized are the ones who don't go to school; who don’t have access to clean water; who don't have access to healthcare when they fall sick and so on.
I think we do have an equity issue in immunization, in the sense that the figure of 80% overall coverage hides that the fact if you drill down to specific countries, that among the poor, coverage rates are universally lower than among the rich. And that is true I think for basically every country.
We clearly need to work on redressing these inequities in order to bridge the immunization gap and bring immunization also to the underserved who actually need it most.
In addition to routine immunization programmes, which I just mentioned, there have also been huge achievements in measles, where we have seen a reduction of mortality due to measles by 71% since 2000.
The global polio eradication program last year saw the lowest number of cases ever reported - just 223 cases worldwide.
The global maternal neonatal tetanus program, which immunizes pregnant women and those of child-bearing age, has also made enormous strides. When it started, in the late 80’s , there were over 800,000 tetanus deaths a year, now that number is down to less than 60,000.
Another area of great progress is in the area of new vaccines. As new vaccines become increasingly available to poor countries, these new vaccines are now being extended to the world’s most vulnerable, further reducing the incidence of illness and death among small children.
A girl presses a cotton ball against the injection site on her arm after being vaccinated at an immunization site, in Ghermu Village in Lamjung District in Western Region, during the nationwide measles-rubella immunization campaign.
In October 2012 in Nepal, an ongoing measles-rubella (MR) immunization campaign to vaccinate children between 9 months and 15 years of age continues throughout the country. The campaign, targeting 10 million children, is the largest-ever public health campaign conducted in Nepal. Measles, an easily preventable but highly contagious disease, is the third-largest killer of Nepalese children. Rubella shares many measles symptoms and usually results in mild infections in children. However, it can cause graver problems and poses a serious threat for a woman’s foetus, including a risk of heart defects, blindness and deafness. Vaccinations against the diseases are being administered at schools, health facilities and other immunization sites, and health teams have been deployed to inoculate children in hard-to-reach urban and rural areas. Children under age 5 are also receiving oral polio vaccine during the nationwide campaign. The MR campaign, launched in February, is led by the Government with support from the World Health Organization (WHO), UNICEF and the NGOs Lions Clubs International and Rotary International. It is part of a multi-partner effort by the Government and the Measles & Rubella Initiative, a global partnership led by the American Red Cross, the United Nations Foundation, the United States Centers for Disease Control and Prevention (CDC), WHO and UNICEF. Worldwide, measles remains a leading cause of death among young children: In 2010, an estimated 139,300 people – mainly children under the age of 5 – died from the disease. Nevertheless, thanks to the Initiative, these deaths decreased by 71 per cent from 2001 to 2011.
How important is making vaccination a political priority?
It is extremely important. Immunization, though it's very successful, it's still an unfinished agenda.
I mentioned the issue of 20% of kids not being immunized. I mentioned the issues of inequities, the fact that polio is almost eradicated and so on. Also for new vaccine introductions, we are encouraging countries to further scale up, specifically with the introduction of new vaccines against pneumonia with the pneumococcal vaccine, and against some forms of diarrhoea with the rotavirus vaccine.
Countries need political commitment in order to do that. You need to have countries see that immunization is important, and that it is important to continue to invest in immunization.
I think that is very important, because we often see that there's a tendency to take immunization for granted. 80% coverage is seen as a big success, but if you don't invest in the program in an on-going basis, you risk losing some of these achievements.
We've seen in a number of countries that coverage has come down because the program got less attention.
Continued investment in immunization is essential, as is keeping it as a political priority. Without that, you don't get continued investment.
Please can you outline UNICEF’s role in new vaccine introductions in developing countries?
Our role in immunization in general is to support governments in strengthening the immunization systems. That can take various forms, depending on which country the program is in and on what our partner agencies are doing.
For example, UNICEF helps countries with the training of health workers. We are also supporting communication so that people understand better why new vaccines are being brought into immunization schedules; why these vaccines are important and against what diseases they protect.
With new vaccines, one of the communication challenges is that the pneumococcal and rotavirus vaccines protect only against some forms of pneumonia and diarrhoea, but not against all.
And so in order to maximize the benefit of immunization, the vaccines need to be introduced hand in hand with other interventions, such as promotion of breast feeding , hand washing, reducing indoor pollution, general hygiene methods, and so on.
The importance of these interventions need to be linked to the messages around the vaccine introduction itself, so that people don't think, well my child is immunized now against diarrhoea and the child won't get diarrhoea anymore - because that is of course, not the case. Rotavirus vaccination only protects against one cause of diarrhoea, albeit an important one.
There are many other causes why kids can still get diarrhoea, even after vaccination with Rotavirus vaccine, and therefore it is important to stress messages around hygiene.
UNICEF is helping governments to set up the systems around communicating with parents and caretakers so that they understand why it's important to immunize their kids, what they can expect from these vaccines, but also that there is more to it than just vaccinating your child. So that's one area that we work on in new vaccine introduction.
Another area where we support countries in this specific field is in the area of cold chains and logistics. If you introduce new vaccines that means you bring in new vaccines in the system, which all need to be kept cool.
We are working with governments to first assess whether the cold chain they have is large enough. And secondly, if it isn't, that then it is being expanded.
But also we look at the quality of the cold chain. These new vaccines are expensive. Vaccines are not only heat-sensitive, but also freeze sensitive. Maintaining the right temperature throughout the cold chain is therefore essential.
Introductions of new vaccine are often an opportunity to have a closer look at how we can further improve the cold chain. For example, in the past, a lot of cold chains were built around refrigerators that were running on kerosene or on gas (in areas with no electricity).
The new developments are that solar refrigerators are becoming more reliable and affordable. We work closely with governments to see, in areas without an electricity grid, how far old fridges or fridges that are due for replacement can be replaced by solar-powered refrigerators.
Cold chain capacity is an issue, as is quality.
These are just two areas where we are focusing on very heavily but of course our support to governments and to programs goes beyond demand creation and cold chain management, but also has to do with training, management, forecasting of vaccine requirements, etc.
Vaccine supply is also a very important area in which UNICEF is very active. Each year, UNICEF buys vaccines for more than a third of all kids in the world. We buy around 2 billion doses of vaccines annually - including new vaccines.
Many of these vaccines are for the world’s poorest countries and the newer vaccines are often paid for by the GAVI Alliance. We work hand in hand with partners to negotiate these prices down to levels as low as possible, so they become more affordable for countries, while at the same time we try to ensure the vaccine market remains healthy.
How has UNICEF worked with other partners to drop the price of new vaccines against certain types of diarrhea and pneumonia?
With partners, we try to estimate what the vaccine needs are country by country, and then of course at the global level. Based on those predictions, we can then start negotiating with manufacturers which vaccines are available and in what quantities.
We put out tenders, so that manufacturers can propose certain offers for the vaccine. The vaccines that UNICEF procures are all WHO prequalified. So these are vaccines of a given standard as set by the WHO. It is not just any vaccine we buy; we buy only vaccines of known quality.
We work closely with a diverse group of partners, from manufacturers to country governments. Countries determine which vaccines they need by when and in what quantities and we help countries project their needs more effectively. More competition in the vaccine market, including from manufacturers in developing countries, of course also helps to bring prices down.
We work with WHO, which advises on vaccine pre-qualification. We also work with donors, and as I mentioned, the GAVI Alliance so that funds are available when needed.
What impact do you think this price reduction will have and what hurdles other than price need to be overcome in order to increase the uptake of new vaccines in developing countries?
Obviously, price reductions make vaccines more affordable, and if we bring the price down, more money is available to improve other parts of immunization programs. This can mean that we can look at whether even more new vaccines can be introduced, or how to further improve the strength of the cold chain, or to strengthen the whole immunization system.
Over time, have seen vaccine prices have come down. This gives a very strong signal that expensive vaccines can become affordable also for poor countries.
The GAVI Alliance supports the poorest countries to introduce new vaccines, and pays the largest part of the vaccine cost. But there is also a co-payment for countries, so countries have to self-finance a small portion of the vaccine price; therefore these new vaccines don't come completely for free.
When countries become richer, they graduate out of the GAVI system. Over time, such countries gradually take over a larger proportion of financing for these newer vaccines, so that after some years they fully self-finance these vaccines.
Unfortunately, there is also a group of countries called middle income countries. Countries like for example, Egypt. These are too rich to be eligible for GAVI financing, but are too poor to afford open-market prices for vaccines. To help these countries, for example in the Middle East, UNICEF and WHO are exploring with countries whether we can set up some kind of a pooled procurement mechanism, where countries pool their procurements for vaccines and then approach the manufacturers as a group, so that they can bring prices down. This would be a way to also make newer vaccines available to children in these middle-income countries.
Girls who are waiting to be immunized watch as a vaccinator fills a syringe with measles vaccine, during an immunization session at Deewan Ballubhai school in the Paldi neighbourhood of the city of Ahmedabad in Gujarat State. Children over age 5 are being vaccinated in schools during the SIA campaign against measles. Six vaccination teams from the Paldi health centre – each consisting of a vaccinator, a community volunteer, an anganwadi worker and a schoolteacher or community worker; and overseen by a supervisor – immunized more than 890 children between 5 and 10 years of age at the private school.
In mid-October 2012 in India, a series of Supplementary Immunization Activities (SIAs) that began in 2010 is aiming to vaccinate all children aged 9 months to 10 years – some 134 million children – in 14 states against measles by the end of June 2013. An estimated 90,000 Indian children die from the disease each year, accounting for 67 per cent of all measles deaths worldwide. Although measles vaccinations for all children under age 1 are part of India’s routine immunization programmes, more than 20 per cent of infants in the targeted 14 states, including Gujarat and Bihar, are not vaccinated against measles. Government-led SIA campaigns in these states are vaccinating children at schools, ‘anganwadis’ (village-level health centres), urban health centres and other fixed locations. And, more than 100 mobile health units are being deployed to reach children in migrant families. Children under age 5 are also receiving vitamin A, to help boost their immunity. SIAs are part of a multi-partner effort by the Government and the Measles & Rubella Initiative, a global partnership led by the American Red Cross, the United Nations Foundation, the United States Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and UNICEF. Worldwide, measles remains a leading cause of death among young children: In 2010, an estimated 139,300 people – mainly children under the age of 5 – died from the disease. Nevertheless, thanks to the Initiative, these deaths decreased by 71 per cent from 2001 to 2011.
One in five children is unprotected against vaccine-preventable illness. Which countries do these children live in and why do you think significant inequalities in child immunization still exist between countries?
There are over 20 million children who are not immunized every year. That's roughly 1/5th of the global birth cohort that is not protected by immunization. When we say that the child doesn't get immunized, what we usually mean is that the child did not get the third dose of DPT or of pentavalent vaccine. That's kind of the indicator that we're using.
Seventy percent of these 22 million unimmunized children live in just 10 countries: Afghanistan, Chad, the Democratic Republic of Congo, Ethiopia, India, Indonesia, Nigeria, Pakistan, the Philippines and South Africa.
There are a number of reasons why children don't get immunized. As I mentioned earlier, usually these are children who are disadvantaged in general terms.
Very often we think about children living in very remote villages, and of course that is often the case. But you also have situations where kids live in cities and are not immunized -usually children living in slums for example. So it's not necessarily the children who live far away in remote areas who are not immunized. It can be kids who geographically can be easily reached but are forgotten about, because they don't fit into plans and existing “structures”.
We also see that unimmunized children are often part of minority groups.
On an individual level, there is a clear correlation between a child’s immunization status and the level of the mother's education. The better the mother is educated, the higher the chance that the child is immunized. And of course, it comes back yet again to the fact that we're talking about children from disadvantaged groups, disadvantaged families.
If you have a situation where the mother didn’t get educated, that would probably be because she is poor, didn’t have the chance to go to school because she needed to work at an early age, etc.
When these girls grow up, and have their own children, they are more likely to not have their children vaccinated.
The inequities between kids who get vaccinated and the ones who don't is not just a matter of living far away. It is related to the inequities of being underserved in general terms and often linked to various cultural or economic reasons.
How does UNICEF plan to help reach the unreached “fifth child”?
We put in place systems that allow us to specifically focus on the un-immunized. We look at available data and map out where are the areas where groups of people live with large numbers of un-immunized children.
Then for these groups, we dig a bit deeper to understand the reason why, in this specific situation, the children don't get immunized. It can be a matter of geographical access that people live far away; or it could be that the health worker in the neighborhood never goes there because either he doesn't feel like it or because he simply doesn't have the time to do it, or doesn't have the money to pay for the transport for example. It can be that there is no fridge and therefore there are no available vaccines. So there can be a number of reasons why these kids are not getting immunized. What UNICEF is trying to do is to better understand what these reasons are, and then try to specifically address bottlenecks.
If it is a matter of no fridge being available, can we buy a fridge, and get the fridge there? If it's a matter of a health worker not doing proper planning, can we work with the health workers to retrain them in how they plan their immunization sessions? If it's a matter of the parents not really wanting immunization or understanding the need for immunization, we see what we can do so that there are information sessions with the parents or village leaders so that they understand that immunization is important, that immunization saves lives. So that's what we're trying to do in countries to reach the fifth child.
How is immunization used as an entry point for other life-saving interventions?
Immunization programs are usually the ones with the broadest reach. Immunizations are often given in three different ways. The first is based in health centers. In a health center, a health worker who works there has access to a fridge there or a cold box where he keeps the vaccine and organizes immunization sessions for people who come to the health center. And sometimes that's on a daily basis, sometimes that's every week, sometimes it's only the beginning of the month depending again on the local situation. Of course, in the health center other services are provided as part of health care provision.
But then what health workers also do is to go to the villages and organize immunization sessions in the villages. We call this “outreach” and it is particularly for communities where it may be difficult for the parents to bring the children to a health facility.
Then there's a third way, and that is doing campaigns. The campaigns are usually larger setups where in a given day or a given week a large group of people or children is immunized in one go. In campaigns, there's a lot of social mobilization around the administration of a given vaccine. You would have for example, measles campaigns, or polio campaigns, or meningitis campaigns. And that's the third way of giving vaccinations.
Both in immunization outreach and in campaigns, other interventions have also been given. Measles campaigns, for example, have been used to distribute bed-nets, or vitamin A. Polio vaccines campaigns for many years have been used to give vitamin A distribution.
Other things that have been distributed with immunization are oral rehydration salts for example. Of course, general health promotion is also something done as people come for immunization in health facilities. You often see mothers wait for their immunization sessions while one of the health workers actually uses that opportunity of having a number of mothers sitting around waiting for immunization to give messages about hygiene, about breast feeding, about nutrition, etc. etc. This happens in many countries. I've seen this very recently in Tanzania for example, where this was happening in a health facility.
There are a number of ways to provide other interventions, but what they all have in common is that immunization is used as the entry point to give other interventions and usually it is because immunization has the widest reach.
Is the current international financing for vaccines sufficient to sustain current progress?
No. I mentioned already earlier that immunization programs require on-going investments. They were all set up by and large in the 80s, and since then we have progressively managed to maintain coverage around the 80% benchmark. But we need to go further; we need to do much more to get these 20% of unimmunized kids down to a lower number.
To do that, and to also maintain or to safeguard investments already made, on-going investments are needed. You need to continue to train health workers and to replace or update an aging cold chain. You need to bring in new vaccines so that the children in poor countries can also have the benefits of immunization that children in richer countries have. All of this obviously costs money.
The good news is that a large number of countries pay for immunization themselves, and have budget lines for immunization. But more can be done, and UNICEF together with partners advocates with governments that they take on a much bigger role in self-financing immunization programs, be it paying for vaccines, or in improving their cold chain, or training their human resources.
Also, having a specific budget line for immunization promotes funding predictability. It's not just a matter of having enough money, it's also a matter of having money in a sustained manner. You can’t build a program if one year you have funding and the next you don't.
Is immunization cost-effective?
Yes, it certainly is. There have been a number of studies done and immunization came out as a very cost effective intervention. As I mentioned already with all vaccines every year, 2-3 million lives are saved as we bring in new vaccines.
Many more can be saved, if we introduced vaccines on a wide scale.
When assessing cost-effectiveness we need to take into account that the alternative of vaccination is, and that is of course, treatment when people fall ill. If we can prevent the disease, we also save on treatment. We see that very clearly with measles, as measles is a huge killer. We brought mortality down by 71% in the last ten years just for measles. That means saving the lives of some 500,000 children – who, if it weren’t for vaccination would have died of measles. These are also children who did not have to be treated, meaning huge cost savings there also.
So it is not just about saving lives, it is also about preventing expenditure on treatment.
What are UNICEF’s plans for the future?
UNICEF’s mandate is the well-being of children and within this, we are promoting the idea of equity very strongly. So for immunization, that means that reaching the fifth child is certainly a high priority. To do that, we need to focus on understanding the reasons for non-immunization and specifically addressing them.
We have, at the global level, a document that was approved last year by the World Health Assembly called the “Global Vaccine Action Plan”, which outlines the way forward for immunization in this decade. Reducing inequities is one of the plan’s main objectives. Another is demand creation.
So for us, working on equity, working on demand creation, on supporting the logistics and cold chain systems, are all areas that UNICEF will continue to work on. And this goes in a broader context of “A Promise Renewed” and a call for action where targets have been set to bring down under five mortality in the future and looking at the post-2015 agenda. Clearly, that cannot be reached if we don't do more on immunization, if we don't reach more kids, and if we don't bring in new vaccines.
For UNICEF, immunization is key to saving children's lives; it's one of the interventions that is very effective. We know that. Further scaling up this intervention is central to UNICEF’s work- scaling up in terms of reaching more children but also in terms of bringing in new vaccines so that we can save more lives.
We don't do all this alone, we work in partnerships. We are a founding member of the GAVI Alliance. We are also a member of the Global Polio Eradication program just to name but a few. On a day to day basis we work closely with partners, governments and communities, and we know very well that by aligning with those stakeholders, we can achieve more than each of us alone.
How important is innovation to UNICEF?
I mentioned the cold chain, where there is more and more focus on solar refrigerators. We now are having solar refrigerators that can operate without batteries, which makes maintenance and use much simpler.
Also we are working on improving the systems behind cold chain, so that we get a better understanding of the temperatures that are maintained within the cold chain equipment, and of stock levels. There have been some innovations on the technology side. For example, there are now data loggers that can be put in refrigerators that measure the temperature on an on-going basis and give alarms if the fridge has been too cold or too hot.
Trying to set up these systems and getting a more widespread use of these small devices is one of the innovations we’re trying to implement. We then want to bring them to the next level by seeing how far can we then combine them with SMS technology, so that problems in the cold chain can be reported and addressed immediately.
In Uganda, UNICEF is using SMS technology with health facilities and with the general public to get information from the field. We are now starting to use this technology to get a better understanding of whether vaccine fridges are still working, where are the stock outs and so on.
So innovation in immunization is a very dynamic field. As technology is improved and our understanding of managerial systems improves, we're also gradually bringing these into the programs.
Where can readers find more information?
UNICEF is making a difference on the ground to extend life-saving vaccines to children in extremely vulnerable situations. More information can be found here: http://www.unicef.org/immunization/
More information on the Global Vaccine Action Plan can be found here: http://www.unicef.org/videoaudio/PDFs/GVAP_single_pages_PRINT.pdf
About Dr. Jos Vandelaer
© UNICEF/NYHQ2013-0353/Susan Markisz
In November 2009, Dr. Jos Vandelaer was appointed Head of UNICEF’s global Immunization programme where he leads strategy development and programme management and coordination. He oversees a team of about 15 professionals.
Dr. Vandelaer started his career with Medecins Sans Frontieres in 1986, working in emergencies in Sierra Leone, South Sudan, Surinam and Thailand.
Between 1989 and 1996, he worked on migration/refugee health for the International Organization for Migration in Vietnam and Croatia/Bosnia-Herzegovina and for the UN refugee agency in Myanmar.
From 1996 to 2001, Dr. Vandelaer served with the World Health Organization as a Medical Officer in Philippines, India, and Myanmar where he worked on immunization, including polio eradication, measles and tetanus vaccination campaigns, and strengthening routine immunization.
Dr. Vandelaer joined UNICEF in 2001 as Senior Health Specialist, seconded to WHO/Geneva with a focus on Maternal and Neonatal Tetanus Elimination. In that capacity he was also a key member of the team that developed the Global Immunization Vision and Strategy, and provided scientific and strategic advice on immunization-related issues.
Dr. Vandelaer holds a Medical Doctor degree from the University of Leuven (Belgium), a diploma in Tropical Medicine from the Antwerp Tropical Medicine Institute (Belgium), and a Masters degree in Public Health from Harvard University (USA). He speaks English, French and Dutch and is a national of Belgium.