Perspectives on the Evolution of Immunization Policy in Low-Income Countries
Since the administration of the first vaccine, immunization policy has evolved to better meet public health needs around the world. This evolution is most apparent when considering immunization policy in developing countries over the past 50 years. Whereas global, top-down processes guided early immunization programs, policies have since shifted to what is now a much more country-driven and country-owned process. This transition has yielded positive results, notably in Latin America, where a concerted effort has been made for local evidence to determine disease prevention and control priorities. The recent elimination of endemic measles from the Americas is an historic milestone and a testament to the fact that a country-driven approach can create unprecedented results. As new vaccines emerge with increasingly complex technical and scientific issues, it is becoming ever more critical that policies evolve to accommodate country-specific constraints such as political will, social values and programmatic feasibility.
The first global-scale fight against a disease began with the World Health Organization’s (WHO) global Smallpox Eradication Program in 1967. At a time when there were 10-15 million annual smallpox cases, 30 percent of which were fatal, the Smallpox Eradication Program was seen as the most ambitious global health initiative to date. The Chief of the Smallpox Eradication Program, Dr. D.A. Henderson, played an integral role in helping the Program to navigate country-specific barriers facing it. Despite environmental, social and political challenges on the ground, Henderson and the Smallpox Eradication Program proved that it was in fact possible to reach everyone on earth. Less than 20 years after the program launched, smallpox was declared eradicated. This feat still stands as one of the greatest public health achievements in history. Around the same time, the Expanded Program on Immunization and the Polio Eradication Initiative began making progress of their own. From these programs, finite strategy points for capacity development emerged that still serve as valuable guides when developing and implementing immunization policy.
Policy began to shift to a more regional focus in the 1980s as new initiatives got underway. Among these new initiatives was the Year of Immunization in Africa, when UNICEF brought a surge of new funding and energy to vaccination campaigns in the region. It was a pivotal moment for many health workers at the time, many of whom quickly saw the value of increasing prevention efforts to reduce the burden of treatment. I was a serving as a District Medical Officer as a Peace Corps Volunteer in Malawi when this exciting new wave of immunization policy moved in and changed the prevention landscape. I left my service knowing that I wanted to dedicate the rest of my life to this work.
In the decades since, immunization policy has become even more localized, with country-driven policies yielding positive results. This trend is particularly evident in Latin American countries, where the WHO and the Pan American Health Organization (PAHO) have promoted country ownership through the ProVac Initiative. Launched in 2004 to strengthen infrastructure and decision-making processes for the introduction of new vaccines, the ProVac initiative has since evaluated vaccines in 14 countries. By establishing immunization policies that are guided by country-specific factors, vaccination programs and their teams are able to use economic analyses to gather a framework of evidence that produces policies best suited for the local environment. From ProVac’s experiences, three key considerations have emerged that are critical to future policies’ successful implementation. They are technical considerations, operational and programmatic considerations and social considerations.
Technical considerations must include disease burden, cost-effectiveness of the vaccine and vaccine characteristics, including efficacy, duration of protection, dosage and immunogenicity. This is particularly important for newer, complex vaccines that do not cover all the serotypes of a disease, such as the rotavirus and pneumococcal vaccines. Policy makers must also consider operational and programmatic factors, such as vaccine supply, partnerships, logistics, and financing strategies. Finally, policy makers must factor in social issues. With vaccine hesitancy, political will and equity varying drastically from country to country, it is essential that policy makers study local culture and constraints to gauge overall acceptability and feasibility. These three considerations are core to creating an evidence package that decision makers can use to develop effective immunization policy.
To strengthen vaccination policies worldwide, the World Health Assembly used these and other considerations to draft the Global Vaccination Action Program (GVAP). The program set six targets, all of which aim to increase equity by ensuring equal access to vaccines around the world by 2020. Today, however, only one of these targets remains on track: the introduction of new and under-utilized vaccines. The successes achieved thus far, while limited, have been made possible by sub-regional support and country ownership, as well as by additional funding from Gavi, the Vaccine Alliance to purchase new vaccines. For GVAP to meet its targets, immunization policy around the world must continue to be built upon country-specific considerations.
The Americas are a strong example of how embracing country-driven policies can yield positive results. The region’s recent elimination of endemic measles – an unprecedented achievement – would not have been possible if decision makers relied on the globally- or regionally-driven policies of the past. By shaping their policies around countries’ unique technical, programmatic and social constraints, immunization programs have been able to flourish with the support of reliable surveillance systems and laboratories. The Americas now stand as a global leader and serve as an example for other regions to follow as they work towards measles elimination.
On the heels of this milestone, the Americas have the opportunity to build on their recent success by applying lessons learned to the elimination of rotavirus. According to the WHO, rotavirus affects 10 million children annually in Latin America, causing 75,000 hospitalizations and 15,000 deaths. Guided by the ProVac Initiative and its country-driven methodology, 17 countries in the region have introduced a rotavirus vaccine and have since seen rotavirus rates decline. Furthermore, cost-effectiveness studies have shown that such country-driven initiatives yield quicker financing and implementation. Programmatic feasibility and financial stability challenges persist, but the region’s overall success highlights the importance of precise policies at all levels. The Americas’ commitment to country-driven policies has the region on track to be the first WHO region to eliminate rotavirus through the use of vaccines.
In today’s era of globalization, disease anywhere is disease everywhere. As the success in the Americas shows, however, regions can make substantial gains towards disease elimination by embracing immunization policies that are rooted in country ownership and sustainability. Immunization policy has a storied past, and there is much to learn from previous initiatives and global health champions like D.A. Henderson as the world pursues the GVAP targets. In order to succeed, policy makers must tackle remaining preventable diseases with country-driven considerations as their guiding principles. The goals outlined by GVAP are ambitious, but they can be achieved if countries commit to maintaining immunization systems that can address the infectious diseases of both today and tomorrow. There must be leadership and champions at all levels. Indeed, our global health security is at stake.