Back to basics on immunisation

The key to attaining immunisation goals is to have skilled managers who can oversee and improve the system, says Elvira Dayrit.

Forty-one years ago, in May 1974, the 27th World Health Assembly established the expanded programme on immunisation (EPI) to protect as many children as possible against six diseases: tuberculosis (BCG), diphtheria, pertussis, tetanus (DPT), measles and poliomyelitis.

By the 1980s, the universal childhood immunisation (UCI) goal pushed for the right of each child to have access to immunisation. Inspired by smallpox eradication, mass immunisation campaigns were launched against polio in 1988, maternal and neonatal tetanus in 1989, and measles and rubella in 2001.

In 2012, the Global Vaccine Action Plan (GVAP) for 2011-2020 was launched with six targets: (1) national DPT3 vaccination coverage of 90 per cent in 194 countries by 2015, with no district coverage less than 80 per cent; (2) no new cases of polio after 2014; (3) global elimination of maternal and neonatal tetanus by end-2015; (4) measles elimination by end-2015 in Eastern Mediterranean, Europe and Western Pacific; (5) rubella elimination from one WHO region by end-2015; and (6) introduction of one or more under-utilised vaccines by 2015 in at least 90 low- or middle-income countries.

Troubling questions

However, the 2014 GVAP report noted that only one of the six key vaccination targets for 2015 is currently on track — the introduction of under-utilised vaccines. Even in this lone success, some questions should be raised. How far were WHO guidelines on new vaccine introduction followed?

The guidelines include measuring several country baselines: specific disease burden, the effectiveness of the new vaccine, financial sustainability and public perceptions. Individually and together, these are quite complicated issues.

The GVAP reported 85 vaccines introduced, noting “all of these introductions were sustained for at least a year”. That is disturbing because, apparently, sustainability was not a serious requirement. Did it even matter who were actually vaccinated?

In the Philippines, four new vaccines have been introduced since 2010 — pneumococcal conjugate vaccine (PCV), rotavirus vaccine, human papillomavirus vaccine (HPV) and h. influenzae b (Hib), the latter with hepatitis B vaccine and DPT in a pentavalent combination. No detailed medium-term plans were drawn.

Vaccination targets for PCV were “high risk groups” such as the poorest of the poor and the elderly. When they chose this target, they had no idea how hard it was to look for the poorest of the poor. Due to limited supplies of rotavirus vaccine, only children living in the “top three geographical regions with high diarrhea incidence” based on routine reports were vaccinated.

There was no baseline on rotavirus disease burden or verification of data quality on diarrhea. Some adolescents in some schools were given HPV. Due to the high cost of the vaccines, the supply of three of the four vaccines newly introduced (PCV, rotavirus and HPV) is not likely to be sustained in the future.

Community response to the quick-as-lightning introduction was also unclear. What was the effect on the viruses? With no baselines, what is there to measure after a year? The Philippines spent millions — and then what?

New vaccine introduction affect especially low and middle income countries. In a recent vaccine conference in Korea, the participant from India admitted that their national programme is “encouraged” to use locally-produced vaccines even if these have not yet passed WHO certification standards. Several countries are now using pentavalent vaccines (5 vaccines in one injection) instead of the original — and much cheaper — DPT. Are market mechanisms rather than health planning principles now driving immunisation programmes?

WHO uses national DPT3 coverage as the indicator of a functional healthcare system. But the GVAP report noted little progress in DPT3 coverage since 2011: “District data are not available, or are invalid, from almost half of the countries.”

The DPT3 indicator has limited usefulness in a country seriously wanting to protect each child. The “full infant vaccination” (FIV) indicator includes only children who completed their primary doses, including their first measles containing vaccine (MCV1) at nine months old. The FIV shifts from antigen-based reporting to child-based reporting. This indicator highlights the drop-out between DPT3 and MCV1 that could be as large as 25 per cent, a huge difference for child protection.

To improve data quality, supervisors can countercheck report consistency with child master lists and conduct immunisation cluster surveys. The Unicef (UN Children’s Fund) supports the use of the FIV indicator but WHO’s reluctance seems to have slowed down the uptake of the indicator in other countries.

The GVAP report notes that by 2015, target dates for stopping global polio transmission have been reset and missed four times, and maternal and neonatal tetanus reset and missed three times. On measles elimination, Eastern Mediterranean and Europe are markedly off track. Western Pacific progress was set back in 2013 by major outbreaks in China, the Philippines and Vietnam. Global rubella vaccine coverage is just 40 per cent.

What’s the way forward?

More than 15 years after the 1996 Unicef report, the 2014 GVAP report arrived at essentially the same conclusion — strengthening immunisation systems is the key to achieving immunisation goals. Of the GVAP recommendations, the key that will solve 80 per cent of the problem is to have “skilled managers who can oversee and improve the system”. In other words, back to the basics.

A revisit of immunisation basics is necessary. Each child should be listed soon after birth. Data quality of reports should be improved with supervisors using indicators like “full infant vaccination” and immunisation cluster surveys to confirm coverage. Health education rather than mere health promotion should be emphasised. Community volunteers should be reactivated to remind parents of child vaccination schedules.

Rather than resetting target dates for disease eradication or elimination, the international community would do better to keep the UCI and all the eradication and elimination targets as continuing goals.

There is a proposal to call countries together to reflect on common strategic solutions. Rather than the current immunisation managers, perhaps previous highly experienced immunisation programme managers — both global and national managers — should be consulted instead. They hold the institutional memory of immunisation basics that was lost during major organisational shakeups and staff turnover over the years.

Without necessarily returning to old guidelines, the insight and hindsight of successful managers of the past could bring immunisation back to the basics while more deliberately and more purposefully redirecting and controlling its future.

Elvira Dayrit is a medical doctor with a master of science degree in mother and child health from the University of London. She was the director for maternal and child health in the Philippine Department of Health from 1987 to 1998. During her administration, full infant vaccination accelerated from 21 per cent in 1986 to more than 90 per cent in 1989, helping the Philippines reach the universal child immunisation goal in three years.

This article has been produced by SciDev.Net's South-East Asia & Pacific desk.