The immunization programme that saved millions of lives

314 Bull World Health Organ 2014;92:314–315 | doi: http://dx.doi.org/10.2471/BLT.14.020514 News In the 1960s, smallpox was still circulat- ing in Africa and Asia. Within a decade of the launch of the World Health Orga- nization’s (WHO) Intensified Smallpox Eradication Programme in 1967, the disease had been wiped out globally. Long before the last case of small- pox was reported in 1977, the idea that a similar approach could be taken with other vaccine-preventable diseases was gaining support. Dr Donald A Henderson, who joined WHO in 1967 to head the Intensi- fied Smallpox Eradication Programme, was struck by how much could be achieved with modest means. “We found very quickly that in Africa the average vaccinator could reach 500 African children a day,” he says. “We wondered ‘why aren’t we doing this with more vaccines?’” But the idea did not take hold im- mediately. And even after the Expanded Programme on Immunization (EPI) was established by a World Health Assembly resolution (WHA27.57) in 1974, it “sputtered along with only one full-time medical officer and secretary, supplemented by part-timers lent from other divisions,” according to the pro- gramme’s first full-time director Dr Rafe Henderson (no relation). In 1977, when it was clear that without more resources, the programme would end, Dr Halfdan Mahler, the WHO Director-General at the time, stepped in, providing over US$ 1 million of WHO’s regular budget to support eight professional and four secretarial staff. “That was a boost,” Rafe Henderson says, “but the breakthrough that set the programme on its future course came when UNICEF was brought in, with its executive director, James Grant, provid- ing funding for national programmes and persuading, if not scolding, national leaders to support EPI”. While other donors joined them, it was the core EPI team at WHO that estab- lished the foundation of this global initia- tive with its cold-chain unit, led by John Lloyd and James Cheyne, “catalyzing a revolution in improved cold-chain equip- ment and logistics,” Rafe Henderson says. Few countries had immuniza- tion programmes and most were just responding to outbreaks, according to Dr Ciro de Quadros, who became head of EPI in the WHO Region of the Americas in 1976, His first step was to get countries to appoint a national im- munization manager. “We brought together the country managers and everyone else from the governments working in epidemiology, primary health care, and so on, and listed the problems – how to improve coverage, do surveillance and organize the cold chain – and analysed them. Then we worked on each problem and solution in each country,” de Quadros says. In the 1970s countries the world over were keen to launch their own EPI but lacked important elements, includ- ing sustainable funding, heat-stable vaccines (in tropical countries), suitable transportation and a system to guarantee vaccine quality. Cheyne and Lloyd worked on vac- cine logistics in collaboration with the United Nations Children’s Fund (UNI- CEF) and its supply division, and soon UNICEF was providing newly designed refrigerators, cold boxes, syringes, needles and sterilizers and other tech- nologies for vaccine delivery. The first cold-chain training course was written in three weeks, tested in Nepal, revised and tested in three other countries so that within four months course materials were ready for distri- bution. “EPI benefited from an organi- zational culture that allowed projects to develop quickly based on a ‘guess and test’ strategy,” Cheyne recalls. Another factor for EPI’s success was the sharing of country data at meetings, which, Cheyne says, put the health ministries under peer pressure to match or exceed the progress that the EPI managers saw in their neighbours’ programmes. The WHO cold-chain unit worked out many of the detailed logistical needs of national programmes and provided training for national immunization managers. In the Democratic Republic of the Congo (DRC), Dr Jean-Marie Okwo- Bele coordinated immunization in three provinces during the 1980s, before taking over as national coordinator of EPI. “The key elements were training provincial and district managers, equip- ping districts with transport – cars, motorcycles and bicycles – and cold- The immunization programme that saved millions of lives What started as an ambitious effort to tackle six vaccine-preventable diseases has become one of the world’s most successful public health programmes. This month the Expanded Programme on Immunization marks its 40 years. Michael Reid and Fiona Fleck report. Community health worker prepares to vaccinate a child in Niger. W H O /U m it Ka rt og lu Bull World Health Organ 2014;92:314–315| doi: http://dx.doi.org/10.2471/BLT.14.020514 315 News chain materials, such as freezers and refrigerators, to keep the vaccines cold,” Okwo-Bele says. “Electricity supplies were scarce, but we received funding to procure kerosene to run absorption refrigerators.” For Okwo-Bele, reliable funding and political backing were essential for his country’s EPI, and DRC had both, thanks to the government, United Nations organizations and partners including USAID, Oxfam and Rotary International. Later, when he led the Polio Eradi- cation Initiative in Africa from 1993 to 2002, the number of endemic countries fell from 34 to just two – an achievement that would not have been possible with- out the African Union’s Yaounde Decla- ration by heads of state and government in 1996 supporting polio eradication. “Nelson Mandela’s personal sup- port for the ‘Kick Polio Out of Africa’ campaign, with his personality and cha- risma, was hugely influential,” says Okwo-Bele, who has been the director of the WHO Department of Immunization, Vaccines and Biologicals since 2004. For Dr Thomas Cherian, who coor- dinated WHO’s EPI from 2006 to 2012, the programme’s achievements far ex- ceed the expectations raised by the 1974 resolution. “Virtually all countries have immunization programmes and most of them have dedicated budgets and effec- tive surveillance systems, which are vital for detecting new cases and monitoring the extent to which a population is pro- tected,” he says. Since the 1980s, the quality of vac- cines has been assured, through the prequalification system managed by WHO, so that these vaccines can be recommended for bulk purchase by UNICEF, the GAVI Alliance (formerly known as the Global Alliance for Vac- cines and Immunization) and other funding agencies. Thanks to prequali- fication and other regulatory systems, more than 90% of vaccines used in national immunization programmes are of an assured quality. Immunization in countries is no longer limited to the six classic vac- cines for children: diphtheria, pertus- sis, tetanus, measles, poliomyelitis and tuberculosis. Infants are vaccinated routinely against rubella, hepatitis B, Haemophi- lus influenzae type b (a leading cause of bacterial meningitis and pneumonia), rotavirus (a major cause of diarrhoea) and Streptococcus pneumoniae bacteria (a major cause of pneumonia). In some countries human papillomavirus vac- cine is included for girls between nine and 12 years of age and routine immu- nization against regionally important diseases such as epidemic meningococ- cal meningitis, yellow fever and dengue is also offered. Given the number of deaths pre- vented – estimated to be in the millions – and the increased potential for deliver- ing new vaccines in future, EPI is con- sidered to be one of the most successful public health programmes to date. Six years into the programme in 1980, global immunization coverage for the first dose of diphtheria-tetanus- pertussis vaccine was 30% and 20% for the third dose (DTP3). By 1990, global coverage for these two vaccinations had reached 88% and 76% respectively, and by 2012, it had reached 91% and 83%. Immunization received a mas- sive boost in 2000 with the launch of the GAVI Alliance, bringing together governments, international agencies, the private sector and philanthropic foundations. Established with a WHA resolu- tion (WHA53.12) in 1999, the GAVI Alliance has made a major contribution to improving access to sustainable im- munization services in countries that are eligible for its funding. Still, many countries are falling short of the ambitious goals set out in the 2020 Global Vaccine Action Plan (GVAP) that countries adopted at the World Health Assembly in 2012. Global vaccination coverage was about 5% in 1974, but the goal now is to reach at least 90% of the population nationally, and at least 80% in every dis- trict. In 2012, 59 countries had achieved this target including several low- and middle-income countries. “It is a mark of the success of EPI that it is setting new, ambitious targets, although some countries may be falling short,” says Cherian, who leads WHO’s work on implementing the GVAP in countries. “Increasing the number of vaccines you administer means you are adding to the strain on the overall health system, so you need to strengthen that.”Thomas Cherian While poor countries may receive funding for immunization programmes from the GAVI Alliance and other donors, middle-income countries can- not afford expensive new vaccines and additional cold storage requirements. “We are seeing much more vaccine production in the developing world. China, India and Indonesia are all sup- plying vaccines that are of an assured quality and are pre-qualified by WHO,” Cherian says, giving hope that more af- fordable vaccines will become available and all countries will be able to attain universal coverage of immunization services. Strengthening public health systems is seen as vital to sustaining EPI’s success well into the 21st century. “Increasing the number of vaccines you administer means you are adding to the strain on the overall health system, so you need to strengthen that, for example, by im- proving health worker training, supply chains and monitoring systems,” says Cherian. An estimated one in five children still do not receive the basic EPI vac- cines. “If there is the political will, the initiative in the countries and the required investment, then these ambi- tious targets can be achieved, as has been demonstrated in many low- and middle- income countries,” Cherian says. ■ The vaccine vial monitor – the image on labels of a square inside a circle – contains heat-sensitive material that registers cumulative heat exposure over time W H O /U m it Ka rt og lu