What are the key reasons why children are missed by immunization programs?
One of the key reasons why children are missed by immunization programs, particularly in developing countries where Médecins Sans Frontières (MSF) works, is that the products that we currently have in their present formulation are not well-suited to the places that have the most un-immunized children. These are the most challenging contexts to work in.
To give an example, about 70% of the more than 22 million children that are missed each year by basic vaccination programs are in 10 countries. It is interesting because this list of 10 countries really hasn’t changed that much over the past couple of years. This is evidence to the fact that we know where a lot of these un-immunized children are and we know the conditions in which they are living. Many of the places in which they are living are also where MSF is operating. The conditions in these places are quite difficult. For example, transportation is very difficult; consistent electricity is very difficult; reaching people that live in remote areas is logistically challenging.
The vaccines that we currently have s limit how much we can overcome these obstacles because vaccines currently require refrigeration. They need to be kept in a very rigid temperature range – between 2 and 8 degrees Celsius – consistently until they are administered. Refrigerating vaccines in a place like Chad that doesn’t have consistent electricity is incredibly demanding. So the fact that they require refrigeration is really limiting in terms of how we can get vaccines out to the most remote places where these large numbers of un-immunized children are.
Secondly, most vaccines in the current WHO recommended schedule require multiple doses. A number of the vaccines require 3 doses at a specific schedule. When you go to places like South Sudan where I was last April you see how difficult it is for a mother to bring her children back multiple times for those multiple-required doses. It is a lengthy trip that requires her to take a day off of work, to use money they don’t have for transportation etc. all to meet the schedule of at least 5 visits to the clinic before the child is 1 year old. Those multiple doses are really a challenging factor of current products.
The thermostability, the multiple doses, the specific schedule are characteristics that have been designed for use in developed countries like the UK or the US where those logistical challenges can be easily overcome. This demonstrates that these products were developed for different contexts. So this is why children aren’t being vaccinated in the places where there are the most un-immunized children.
Why do many vaccines have to be refrigerated?
I am not a scientist so I can only give a partial explanation but vaccines have differing levels of thermostability, i.e. how long they can remain efficacious, or potent, outside of the cold chain. While vaccines may have different thermostability profiles – different sensitivities to heat – it is a blanket recommendation that they be kept at 2 to 8 degrees Celsius because that is where we have the most data on their lifespan.
Something that MSF and the global community are working on is trying to push for more thermostability data. We do know that manufacturers of these vaccines have a lot of data collected during their trials on how vaccines can ‘live’ outside of the cold chain. A big advocacy point for us is to push to make that data available and see whether some of these current vaccines that we have can be relabelled for additional thermostability.
For example, meningitis A vaccine, which is a very successful project to develop a vaccine specifically for the type of disease in the African meningitis belt, relatively recently – in the last couple of months – was approved for use outside the cold chain for 4 days of up to 40 degrees Celsius. That’s really a success, because in large meningitis campaigns that means that logistically we can reach more children. Some regions of Chad don’t have a consistent supply of electricity, despite this, we can take meningitis A vaccine to that region and we know that it can be out of refrigeration for 4 days and that facilitates reaching more children. So mirroring meningitis A, we need to look at what can be done for the other vaccines and see if there’s room for extending their life outside of the cold chain as well.
How has the cost of vaccinating a child changed over the last decade?
It has changed dramatically. We did a costing of the WHO recommended package of vaccines in 2001 and found that it was almost $1.40. Ten years later with the addition of new and more expensive vaccines, we saw that that price was almost $39. That’s an increase of 2,700% in a relatively short time-frame of just 10 years.
What are the reasons for this change?
There are a couple of things that are contributing to the change. One is that new vaccines have been added to the vaccination schedule. This is a success as these new vaccines are incredibly lifesaving so their global use is to be celebrated. But the cost of these new vaccines is incredibly high, especially compared to the older, more traditional vaccines. For example, these two vaccines - pneumococcal conjugate vaccine (pneumonia vaccine) and rotavirus vaccine (which protects against diarrhea) - alone cost about 70% of the whole package of WHO recommended vaccines.
The prices are high – why? Well there is relatively little competition. There are only 2 WHO pre-qualified manufacturers for the PCV and rotavirus vaccines each. So there is a duopoly and this is not creating the competition that we have seen can really bring down prices.
The increasing cost of fully immunizing a child is of great concern and it’s particularly of concern in the context of countries that are losing donor support and are going to have to pay for these vaccines completely themselves. They’ve done the introduction of these new vaccines with donor support, but when they lose donor support these relatively high prices may threaten the sustainability of their immunization programs. To me it is really the great human experiment of seeing when donor funding ends what will happen to the sustainability of these high cost immunization programs. That’s why it is very important to pay attention to the price of vaccines so we can track the accountability within that sector.
Please can you give a brief introduction to the ‘Decade of Vaccines’ blueprint?
The Decade of Vaccines is an initiative launched by Bill Gates. He announced it in 2010, where he said the next 10 years will be focussing on increasing access to immunization for everyone. This is a laudable goal and MSF strongly believes in the importance of improving access to immunization services. The Decade of Vaccines essentially outlines what we are going to do as a global immunization community. It has a number of goals around eradication and elimination targets, such as eradicating polio, eliminating diseases like measles and so forth.
There are goals in terms of increasing coverage of vaccines. As I mentioned earlier there are still 22 million children being missed every year by vaccination programs – that’s 1 in every 5 children. 20% of all the children born annually around the world do not get their basic vaccines. So there is an aspect of this Decade of Vaccines that plans to narrow this gap – particularly in countries that have very poor vaccine coverage.
There are other aspects of the Decade of Vaccines that cover research and development (R&D) – so developing new vaccines. There are also aspects around making products that we currently have more appropriate, such as extending thermostability, adaptation and so forth. However, there are also some gaps in the Decade of Vaccines action plan.
Does the vaccine blueprint for the next decade include control measures to monitor vaccine prices?
It does not which we think is a significant shortcoming of the global vaccine action plan. The latest work on the Decade of Vaccines has been to develop the indicators and targets to measure progress towards the Decade’s goals. There is a set of proposed indicators that are being discussed and which the WHO World Health Assembly will consider in May.
To me it’s a reflection of the importance – of lack of importance – that the leaders of the Decade of Vaccines put on vaccine prices in that there is not an indicator to track price. The Decade has initially been costed at more than $50 billion and that’s only costing it for a subset of countries. An important part of that budget that was also left out was the R&D costs. $50 billion is a lot of money considering the global financial climate. We know that a large part of that budget is composed of how much the vaccines themselves cost because vaccines are expensive.
To ensure the sustainability of immunization programs, and to push for cost savings in the Decade of Vaccines, we believe it is of the utmost importance that we are tracking vaccine prices, and have targets for reducing the cost of vaccines. This would affirm that we as a global community want to see prices come down, and that we have put forward clear measurements to monitor this. This is about how we as a global vaccines community are accountable.
Is it important to monitor vaccine prices and what do you think is the best way to do so?
It is not MSF’s role to be tracking what has happened to vaccine prices over the past 10 years, however no one else is doing this! We put out a report last year, called The Right Shot: extending the reach of affordable and adapted vaccines. This was the first such report that has more comprehensively looked at changing vaccine prices for the past decade. It’s surprising that there aren’t other global bodies who are responsible for this –it is a very important element of sustainability!
If we are going to have a meaningful Decade of Vaccines, tracking the actual cost of vaccines themselves needs to be a part of that. When the WHO World Health Assembly reports back each year on the progress towards the Decade of Vaccines, we should be able to very clearly and objectively look, as a global community, to what has been happening with vaccine prices. We can only really achieve this if we have an objective indicator - we can’t just talk around these things. We know that what gets measured gets done. It is essential that there is an indicator in the monitoring framework for the Decade of Vaccines.
Why are many vaccines ill-suited for use in developing countries?
MSF has really interesting feedback from the field because we are delivering vaccines in a number of these countries that have high numbers of un-immunized children. I can speak from my experience in South Sudan in April last year. I met a mother who had two older children who had not been fully vaccinated - at this point they were older than eligible for immunization. She was at the clinic bringing her twins for vaccination. She expressed to us that she knows vaccination is important and she wants to have her children vaccinated – and that is why she had walked for hours that day to get to the clinic for her twins’ vaccination. But for her older children she hadn’t been able to come that many times considering the travel it required. So we need vaccines that we can take out to people like her.
How can this problem be solved?
Vaccines that can facilitate us doing outreach and that don’t require such heavy logistical capacity – that don’t require the cold chain; that we can give in one dose; an easier to use administration technology so that a lay community health worker could administer the vaccine. We know that with the polio vaccine, which is an oral vaccine, the polio eradication initiative has been really able to progress towards eradication because they have an easy-to-use tool. This essentially means anyone can be a vaccinator – anyone can administer these two drops in a little plastic dropper. We need to take this experience and see if we can apply those characteristics to the vaccines that we have.
Would you like to make any further comments?
The target in the Global Vaccine Action Plan for adapted technology is for only one vaccine using more innovative vaccine delivery technologies. So by 2020 – the end of the Decade of Vaccines – we are measuring our success if we have just one new vaccine administration technology. We don’t think that is sufficient. There are hundreds of these technologies that are being developed and many of them are close to receiving WHO approval. So the target of just one in a ten year period is very unambitious.
Where can readers find more information?
They can find out more on our MSF access campaign here: http://www.msfaccess.org/
They can also find more information on the Decade of Vaccines campaign here: http://www.dovcollaboration.org/
About Kate Elder
Kate Elder is the Vaccines Policy Advisor for Médecins Sans Frontières's (MSF) Access Campaign. The purpose of the Access Campaign is to push for access to, and development of life-saving and life-prolonging medicines, diagnostics and vaccines for patients in MSF programmes and beyond.
Prior to joining MSF, Kate worked with the International Federation of Red Cross and Red Crescent Societies (IFRC) in Geneva, Switzerland, as a Senior Health Officer focusing on vaccines.
In addition to her experience in vaccination policy and advocacy, Kate has worked in HIV/AIDS education with UNESCO, and spent time living in Africa (Botswana) to conduct research on adolescent sexual and reproductive health.
She has a MSc in International Health from Charité Medical School (Freie and Humboldt-Universität Berlin), University of Bergen (Centre for International Health) and l’Université Bordeaux Segalen (L’Institut de Santé Publique, d'Épidémiologie et de Développement (ISPED)).