The State of the World's Vaccines and Immunization 2000
The World Health Organization, Geneva, Switzerland
Section one: why vaccines?
An ounce of prevention is worth a pound of cure.
Thus carolled Benjamin Franklin, legendary American man of letters, epigrammatic homilies, and founding father of contemporary electronics. Although Franklin lived in a time when infectious diseases accounted for fully 80 percent of premature deaths, his words ring as true today as they did nearly 200 years ago. Today, prevention isn't measured out in ounces, but international units, subunits and micrograms. Immunization has not only saved countless lives, but continues to provide the best hope against undefeated scourges such as malaria, tuberculosis, and meningitis as well as emerging infectious diseases such as HIV/AIDS.
Nevertheless, despite a largesse of new and improved vaccines and widespread immunization coverage in developed nations, fully 30 million impoverished children continue to go unvaccinated. Despite numerous treaties, initiatives and good intentions, fewer than one in three children world-wide is immunized during their first year of life. Almost one million children will die of measles this year—even though safe vaccines are widely available at low cost. An additional 215,000 will be killed by neonatal tetanus contracted after their non-immunized mothers give birth on dirt floors, while many thousands more will succumb to yellow fever, diarrhoeal diseases and respiratory infections—diseases easily preventable with vaccine technology that has been around for years. Millions more will be crippled, blinded, suffer liver cancer or life-long brain damage as a result of infections that could have been avoided with motivation, planning and acceptance of the moral imperative to ensure quality healthcare for all people—regardless of race, gender or socioeconomic status.
HUMAN RIGHTS, IMMUNIZATIONAND POVERTY Seventy per cent of all deaths from communicable diseases occur in children between 0–14 years of age. The majority of these are in developing countries where complex epidemiological factors means children fall ill with multiple infections aggravated by malnutrition and poverty. Such children have no access to even the most basic healthcare —their short lives beginning and ending in suffering and want. Yet, the 1989 UN Convention on the Rights of the Child clearly stipulates that immunization is a basic human right.
So why then are so many children still dying?
Poverty is the real culprit. It is the leading cause of shortened life spans, disabilities and starvation. It is the reason why so many children go unvaccinated and it is the reason why infectious diseases continue to kill and maim the world's most impoverished and vulnerable populations—children living in critically reduced circumstances. Every death, every case of blindness, brain damage, hearing loss or disability constitutes a denial of basic human rights. From the perspective of the Convention on the Rights of the Child, the rights of impoverished children are being systematically violated in all categories.
Stagnating rates of immunization coverage Since the successes of the early 1990s—which saw global immunization coverage rates peak at 80 percent—numbers have stalled and fallen back to well below 75 percent in many nations. Nowhere does the gap yawn wider than between poorer developing countries and more-privileged industrialized counterparts. Among the disenfranchised are those oppressed by the highest burden of disease mortality – the children and young adults of sub-Saharan Africa, Asia, South America, and the fragmented breakaway republics of the former Soviet Union. In Africa, more than 50 percent of all children have no access to the basic vaccines recommended in the Expanded Programme on Immunization (EPI), while in the rest of the developing world, immunization is often inconsistent and riddled with delivery problems. The reasons are legion. Chief among them is a lack of political will on the part of governments who refuse to endorse public health as a social priority. Others include extreme poverty, geographical barriers, civil strife, ignorance, safety issues and low profit margins facing manufacturers seeking to sell vaccines to populations who can barely afford to put food in their mouths, let alone vaccines.
Although a brave new world of genetically engineered vaccines has been with us for well over two decades, newer vaccines against Haemophilus influenzae (Hib) and promising candidate vaccines such as those for Japanese encephalitis and dengue will remain unaffordable and therefore beyond the reach of those who need them most.
Other vaccines still in development face some formidable scientific hurdles. These target HIV/AIDS, malaria, shigellosis, respiratory syncytial viral infection and a host of other respiratory pathogens rife in developing countries too impoverished and too small to offer any market inducement to large manufacturers. Some vaccines are affordable and safe (against tuberculosis and cholera), but fail to confer any lasting immunity.
A cost-effective alternative In many countries, health care services are ‘lame ducks’ crippled by war, economic chaos or burdened with a mind set that favours treatment over prevention.
And yet, numerous studies show that effective immunization delivered early on in life can enhance the economic well being of an entire society. As a preventive measure, vaccination is cheaper than the alternative of expensive hospital stays and treatment with antibiotics (increasingly ineffective in the face of antimicrobial resistance), has fewer side effects and, in most cases, confers life-long immunity against some of the most virulent pathogens known to humanity.
To that end, vaccination remains the most cost-effective intervention (rivalling hand-washing and basic hygiene) in the global health care arsenal. Even if immunization is the only medical attention a child receives in his/her natural lifetime, benefits are substantial and extend far beyond the individual and into the community at large.
A firewall against antimicrobial resistance Another area where accelerated vaccine introduction looms large as a potential saviour, is the prevention of diseases now becoming untreatable in the wake of flagging antibiotic efficacy. The honeymoon is over for those of us who are wedded to the idea that infectious diseases are easily curable. The upsurge of antimicrobial resistance holds troubling implications for all peoples regardless of whether they live in developing nations or not. Like a persistent guest who flatly refuses leave, multi-drug resistance is here and is here to stay. Of the seven leading killers of young people and children, only one—measles—is vaccine-preventable. Three—acute respiratory infections, malaria and diarrhoeal diseases—are showing worrying increases in resistance to first, second and third-line drugs. In laboratory samples as many as 70 percent of respiratory infections are resistant to first-line antibiotics, while shigella—a highly-transmissible bacterium that causes 1.1 million deaths in developing countries each year—is resistant to almost every antibiotic drug available. Resistance to ciprofloxacin—the only viable medication left in the anti-shigella arsenal—is just around the corner.
By preventing infection and disease in the first place, vaccines and vaccination offer the best solution to a burgeoning threat. Because vaccine development typically takes some 15 to 20 years from inception to product, it is imperative that the global community act now to allocate resources necessary to prevent increasingly drug-resistant infectious diseases easily trounced only a decade or two ago. As one WHO scientist bluntly stated, “antimicrobial resistance will drive vaccine development over the next 20 years.”
A (very) short history of vaccinology Taming the speckled monster: Edward Jenner and the eradication of Smallpox
But first, let us step back a bit—200 years to be precise. It is Edward Jenner who most modern historians honour as, “father of vaccinology.” Born on May 15, in Berkeley, England, young Jenner was an avid naturalist, who first became acquainted with smallpox and smallpox immunity while attending school. In those days, smallpox was a dreaded scourge that scarred and maimed those it didn't actually kill. According to historians some half a million Europeans were dying of confluent smallpox each year. Survivors were often left blind and pocked with numerous scars and lesions. Dubbed, “the most terrible of all the ministers of death,” by the British scholar Macaulay, smallpox exerted a profoundly horrible influence on history—the destruction of armies, the deaths of kings and the so-called ‘conquest’ of the New World have all been attributed to the disease’s malevolent spread.
So dreaded was the ‘speckled monster,’ that many sought to avoid facial disfigurement by opting for ‘insufflation’ otherwise known as ‘variolation’—a practise introduced into Europe from Turkey by Lady Mary Wortley Montague in 1721. Lady Wortley was the wife of the British Ambassador to Constantinople whose reputation for beauty had been the talk of Europe before a smallpox infection left her pocked and scarred. Whatever the risks, Lady Wortley’s children were not going to suffer the same fate. The French philosopher Voltaire had once reported that the Circassians (an ethnic group living in Turkey) routinely innoculated their daughters with smallpox in order to avoid disrupting the lucrative trade in beautiful young damsels destined for the Sultan's seraglios. Ignoring the advice of her physician who condemned the practise as "unchristian", the good lady went ahead and had her children innoculated—thereby protecting them from later infection. In due course, the practise of variolation spread throughout Europe and thence to the Americas.
Many however, credit the Chinese for pioneering the technique of selectively inducing a milder, less-disfiguring form of the disease by grinding up smallpox scabs and inhaling the crusts through the nostrils. Although historians believe the technique was widely practised from the 6th AD century onward, the first written record is attributed to a Buddhist nun living during the reign of Jen Tsung in 1022 to 1063 AD.
In the Correct Treatment of Smallpox the author recommends selecting scabs from people with only a few pustules—preferably one month old (barring hot weather when scabs aged 15–20 days would suffice). These scabs were then dried, ground together with various medicinal shrubs and plants, and blown or inhaled into the nostrils via a silver curved tube. Other accounts are more disagreeable.
In “The Golden Mirror of Medicine” another Chinese author (an anonymous one) details four inoculation methods: • Plugging the nose with powdered scab laid on cotton wool • Blowing dried scabs into the nose • Clothing a healthy child with the undergarments of an infected child • Stuffing the nose with a piece of cotton smeared with the contents of a smallpox pustule.
Although such techniques using primitive ‘attenuating’ methods conferred a certain amount of protection against more disfiguring forms of the disease, results were often unpredictable. As many as 2–3 percent luckless recipients died or were seriously maimed from smallpox infection acquired through variolation itself. Jenner volunteered to ‘buy the smallpox’ (referring to variolation) soon after graduating from medical training. His experiences may have changed the course of human history.
On May 14, 1796, Jenner was ready. After years of clinical practise he became almost certain that cowpox infection conferred life-long immunity against its more virulent cousin. Like many of his contemporaries, Jenner observed milkmaids, and those working in close proximity alongside cattle and horses, rarely suffered from the affliction. One cattle-breeder successfully inoculated his family during a smallpox epidemic by pricking his wife's and two children's skin with pus harvested from one of his cowpox pustules. The experiment succeeded and his family remained immune for 15 years. Jenner was intrigued.
On May 14, 1796 he innoculated eight-year-old James Phipps with cowpox vaccinia taken from a sore on milk maid's hand. After a mild illness that lasted seven to nine days, a vesicle formed and fell away. On July 1, Jenner was ready to act. In a move that nowadays would have the entire medical ethical establishment howling for his head, Jenner intentionally infected young Phipps with human variola, the virus that causes smallpox. He waited a few months and tried again. Nothing.
In a letter to friend Edward Gardner, Jenner gleefully wrote:
But now listen to the most delightful part of my story. The boy has since been innoculated for smallpox, which, as I ventured to predict, produced no effect. I shall now pursue my experiments with redoubled vigour.
The world was never to be the same.
Like other revolutionary medical interventions, innoculation was not without its' detractors. Many considered it against the “will of God,” while still others conjured up fears of an 18th century cattle-based "Frankenstein", a reconfiguration of the human mammal that would result in a new race of cow-headed minotaurs half man, half bovine.
For the most part however, Jenner's technique was welcomed as a panacea, a man-made product of the enlightenment that was sure proof of man's superiority against the more insidious and unpredictable of Mother Nature's microbial progeny.
Eventually, vaccination was imported to the Spanish Colonies of the New World through the serial arm-to-arm innoculation between orphan children in what today would be considered ethically questionable practise.
The 1803–1806 Expedicion de la Vacuna (otherwise known as the Balmis-Salvany expedition) was responsible for the successful vaccination of thousands of people living in the New World and Asia. In what became later known as a public health first, Francisco Xavier De Balmis shipped out of Spain with 22 orphan children to embark on an officially sanctioned programme of mass immunization overseas. The vaccine was maintained throughout the campaign by sequentially immunizing the children from arm-to-arm—effectively creating a living chain of readily available live vaccine.
The expedition was notable for other reasons as well. In every community targeted for vaccination, De Balmis and his cohorts conducted a series of public information meetings explaining the virtues and drawbacks of vaccinia vaccination—supported by written documentation describing the procedure to fledgling vaccinologists.
Following enactment of legislation enforcing mass immunization of young children against smallpox in Britain during the mid-1880s, Jenne’s mission was finally complete. In a subsequent address to the International Medical Congress in London, Louis Pasteur conferred the ultimate accolade by extending the term “vaccination” to include all immunizing agents.
Early in the 19th century however, Jenner, fellow clinicians and their patients soon realized that vaccination with vaccinia failed to confer life-long immunity against smallpox. Overall mortality decreased, but repeated outbreaks testified to the smallpox virus’s stubborn persistence. In 1958, The World Health Assembly proposed the World Health Organization should spearhead the eradication of smallpox from each and every neighbourhood, city and country around the globe.
The development of freeze-dried vaccines, the bifurcated needle and sophisticated surveillance systems eventually led to the eradication of the disease. In 1980, the Thirty-third World Health Assembly solemnly declared the world free of smallpox.
Sadly, the smallpox story doesn't quite end there. With the eradication of the disease in the late 1970s, immunization of the general population ceased. Eventually all immunization programmes targeting military personnel also stopped. With no market for a vaccine, manufacturers lost interest and quit research into second generation vaccines.
Today, an estimated 10 former-Soviet Bloc countries possess stockpiles of smallpox virus. According to a recent report from the US National Institutes of Allergies and Infectious Diseases (NIAD) the former Soviet Union had an active smallpox programme until well into the 1990s. Some fear that newly independent and breakaway republics may have acquired caches of the highly virulent deadly virus. Any release of smallpox whether deliberate or accidental could spark a global health emergency because the disease would spread faster than vaccine could be manufactured.
In the United States, federally sponsored research is currently underway by the Centre of Disease Control (CDC) and the National Institutes of Allergies and Infectious Diseases to counter the threat of biological terrorism posed by the deliberate release of smallpox.
Despite these anxieties, WHO recognizes only two sources of variola stocks: at the CDC itself and a centre in Novosibirsk in Russia. In 1996, the World Health Assembly resolution 49.10 set the date of 30 June 1999 for the destruction of all smallpox stocks. Four years later, the Assembly delayed that date to not later than 2002. The march of immunization: From pasteur to polio eradication Following the release of Jenner’s first treatise on Variolae Vaccinae, 87 years would elapse before the world would have another vaccine this time against rabies. During that time, the field of vaccination remained lively, with concerns aired over the safety of traditional arm-to-arm vaccination. Fears that syphilis and other infectious diseases could be transmitted along with vaccinia virus prompted German scientists to use glycerine to kill bacteria thereby ensuring a fairly safe killed vaccinia supply of consistent quality.
In the latter half of the 1800s, French biologist Louis Pasteur drew upon the discoveries of the previous 40 years—attentuation of live viruses in order to weaken them, immune enhancement through animal passage and the tendency of pathogens to revert to virulence to develop an attenuated chicken cholera virus for vaccination of poultry.
Further experiments involving vaccination of sheep and goats with his new anthrax vaccine boosted Pasteur's confidence. In 1885, he immunized two males with an attenuated rabies virus, thus unleashing an angry public outcry. That anyone would knowingly introduce a deadly virus into another human being was beyond outrage. For the unlucky subject that eventually developed rabies, immunization was tantamount to medical murder – no matter how weakened the vaccine strains were. That both men had already been bitten by rabid dogs and were therefore at risk of dying a slow and ghastly death did little to deter an avalanche of public censure.
In 1884 Russian microbiologist Elie Metchnikoff published his theory of cellular immunity. Earlier, he had successfully identified those body cells that gobble up and destroy invading microorganisms as phagocytes known today as macrophages. At the end of the 1800s the work of the previous five decades finally paid off with a flurry of new killed vaccines against typhoid, plague and cholera. In one of those strange coincidences that seem to characterize scientific research, different teams of researchers developed many of these vaccines simultaneously and independently. Scientists working independently in developed a killed typhoid vaccine and in England simultaneously. One of the developers went on to create a heat-killed cholera vaccine in 1896.
In 1894 Japanese and French microbiologists identified and named Yersinia pestis as the bacterium that causes plague. Some years later Russian émigré scientist Waldemar Haffkine was working on a cholera vaccine in India when an outbreak of pneumonic plague in Bombay prompted him to abandon research and concentrate on vaccines against ‘the Black Death’ instead. In what was to become a venerable tradition among vaccinologists, Haffkine injected himself with his new killed vaccine before conducting trials on others. Within weeks, more than 8,000 individuals were vaccinated against a scourge that had hounded humanity for centuries.
The advent of the 20th century saw an explosion in vaccine research and discovery with the dizzying introduction of vaccine after vaccine including those against tuberculosis, yellow fever, influenza, measles, tetanus, pertussis, mumps, rubella, diphtheria, Japanese encephalitis and hepatitis B.
The introduction of Jonas Salk’s inactivated polio vaccine (IPV) followed by Albert Sabin’s live-attenuated oral polio vaccine (OPV) in the early 1950s sparked yet another global eradication effort this time against polio.
Ethics and Immunization trials The public good versus individual rights has, until quite recently, been one of the over-riding dilemmas of vaccination research. Previous to the advent of modern-day human trials—which today require rigorous safety and efficacy protocols—vaccine development was a hit and miss sort of business that frequently ended in triumph or tragedy depending on which end of the needle you were on.
By today’s standards, Jenner's experiments on James Phipps could be interpreted as medical abuse. After receiving the innoculation of cowpox latterly referred to as vaccination—Phipps was ‘variolized,’ to confirm that vaccination had indeed protected him from smallpox. Granted, variolization carried a 1–2% risk of death, but for many the alternative of being maimed or killed by smallpox was far more horrifying than relatively slim risks posed by innoculation.
Despite ample anecdotal evidence pointing to the protective effects induced by cowpox, Jenner's decision to deliberately infect young Phipps (a minor) with deadly smallpox following innoculation with cowpox has been compared to vaccine experiments undertaken by Nazis during the Second World War. Luckily for Jenner (and Phipps) the scientist's hunch paid off resulting in millions of lives saved and the eventual eradication of a deadly virus the first time a disease had been vanquished by human intervention.
Today's CIOMS-WHO International Ethical Guidelines for Biomedical Research Involving Human Subjects traces its origins the Helsinki Declaration and the Nuremberg Code a document excoriating Nazi practices and one of the first manuscripts detailing ethical medical research guidelines involving humans. History is indeed written by the winners. If Jenner's experiment had resulted in Phipp's death or if Nazi doctors had been on the winning side and successfully developed a vaccine against typhus, who would be extolled and who condemned?
Today, these questions (and possible answers) have taken on greater urgency as the world gears up for a series of major phase III HIV/AIDS and other vaccine trials involving human beings. Like smallpox in Jenner's day, HIV/AIDS appears to be incurable and constitutes a contemporary plague—derived from the Greek word plege meaning, "to strike without warning". And like smallpox, HIV/AIDS is a highly-stigmatizing disease that disproportionately afflicts the vulnerable. It stands to reason therefore, that vaccine trials currently underway in Canada, Europe, Thailand and the USA involve the recruitment of volunteers representing at-risk populations.
Owing to this combination of enhanced risk and enhanced vulnerability, ethical considerations behind HIV/AIDS vaccine trials in developing countries must take into account a variety of factors. These include the social stigma of participating in such trials, lack of education on basic human rights, minimal awareness of how the virus is transmitted and economic pressures that may tempt poorer candidates into volunteering for trials that clearly contravene their own best interests.
To date, 8,000 people have volunteered. Many are injecting drug users (in Thailand) men who have sex with men and other at-risk populations who have been counselled extensively on their rights, how to prevent infection and what to expect from vaccination trials. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has published Ethical Considerations In HIV Preventive Vaccine Research which outlines a series of guidelines designed to ensure the rights of volunteers participating in vaccine trials are protected.
Standing on the shoulders of giants: Building routine immunization and healthcare through polio eradication For poliomyelitis the year 2000 is not just the first year of the new millennium but the beginning of the end for a deadly contagion that once killed and crippled millions. Today, it is on the verge of being eradicated from the world forever.
In 1988, the World Health Assembly launched the largest global health initiative in human history—the eradication of poliomyelitis—greater even than the eradication of smallpox. Today, expanded immunization coverage has led to an extraordinary push towards global eradication certification by the year 2005.
The genesis of National Immunization Days (NIDS) has also triggered an unprecedented interest in routine immunization coverage along with enhanced healthcare delivery to some of the worlds' most neglected and marginalized populations. In 1999, the Congo and Sierra Leone conducted their first national immunization days; they were the last two countries in the world to introduce them. Indeed, such is the commitment to global polio eradication that conflicts and wars have been suspended for mass polio immunization campaigns—otherwise known as ‘Days of Tranquillity.’
WHO and UNICEF, in tandem with partners, various governments and rebel armies, have successfully brokered ceasefires to ensure vaccination of children living in war-torn areas —Afghanistan and the Democratic Republic of Congo are just two examples. By throwing the entire weight of the United Nations to bear on these ‘Days of Tranquillity,’ the global community secures access to all children and the safety of those working on their behalf.
Today, polio eradication is progressing smoothly towards its ultimate goal. In 1998, poliovirus hit 350,000 people—most of whom were young children. By 1999, that number had dropped to 7,000. By January 2000 indigenous transmission of poliovirus has been interrupted in the Americas, Europe and Pacific regions. Only 30 countries worldwide remain endemic and WHO estimates no more than 20,000 people now carry the poliovirus—a drop of 98 percent.
The disease Poliomyelitis is caused by infection with one of three types of poliovirus belong to a group known as enteroviruses; that is, viruses that reside on the gut. All three are capable of causing acute flaccid paralysis—meaning muscles are floppy and devoid of tone and reflexive response.
The poliovirus infects only human beings and has no reservoir other than man. Spread from person to person primarily through the faecal-oral route, the virus tends to appear in areas where sanitation is poor. In industrialized nations person-to-person transmission occurs primarily via the respiratory route. Those infected are typically infants and children under five years of age. Victims remain immune for life—to that particular serotype. Unfortunately, cross-immunity against the other two serotypes does not occur. Before the widespread introduction of injectable and oral vaccines, polio could strike anyone living in any country around the world. In many nations, the disease has a tendency to flare up during the hot and humid summer months—with the usual incubation period between one or two weeks for paralytic cases.
Upon infection, the poliovirus multiplies in the pharynx and intestines before spreading through the regional lymphatic system into the bloodstream or up the nerve fibres before attacking the spinal cord and the brain. Once entrenched in the nervous system, the virus selectively attacks the motor neurons of the spinal cord and/or brain stem severing the nerve links to leg, arm or back muscles leading to paralysis and disability.
In more that 90 percent of those infected, poliovirus causes no symptoms whatsoever. Between 4–8 percent of victims will experience only mild illness—otherwise known as abortive poliomyelitis. Because symptoms are non-specific, medical workers have difficulties distinguishing the infection from other mild viral maladies. Unlike more serious manifestations, there is no paralysis and recovery is rapid. Both in-apparent and mild infections can be transmitted to others who may be more vulnerable to serious acute illness —such as pregnant women, children and those recently undergoing tonsillectomy.
About one in 10 out every infected 1,000 individuals will be laid low with serious paralytic disease. Of those, about 1 percent will go on to develop aseptic meningitis.
Paralytic polio begins much the same way as abortive polio. Paralysis comes quickly —sometimes arriving in mere hours—with tendon reflexes the first to go, followed by muscle weakness (usually on one side) and paralysis of the large proximal muscles of the legs, arms and back. In severe cases, paralysis of the thoracic, trunk and abdominal muscles leave patients quadriplegic. Spinal paralytic poliomyelitis is the most common form of paralytic polio: resulting in flaccidity of the trunk, legs and arm muscles. Though less common, ‘bulbar’ paralysis affects the cranial nerves of the brain stem leading to respiratory distress, difficulty in swallowing eating and speaking. For those who have pored over black and white photos showcasing rows upon rows of children encased in iron lungs, it is paralytic polio that conjures up the most sinister images. Stiffness of the neck, particularly in the early stages, is a sure sign that the infection has progressed to the meninges—the tough protective sheath covering the spine and brain.
A race to reach the last child Today the world is in a race to reach the last child. So far, WHO numbers reveal polio eradication is preventing some 500,000 infections per year. Almost 2000 million children have been immunized during National Immunization Days during the last five years alone. In one single day, medical workers vaccinated 147 million Indian children. In one year a total of 450 million children received polio vaccine—fully two-thirds of the world’s children.
In keeping with polio eradication's original mandate, primary health care delivery is receiving a tangible boost. To date: • Millions of healthcare workers and volunteers are now trained to provide healthcare services in their own backyard a major boon to remote communities struggling with inadequate access and poor treatment. • Polio eradication has been used to deliver other health care services. More than 50 countries have provided vitamin A supplementation during National Immunization Days. • Polio eradication is paving the way for routine immunization services in previously un-reached populations. The development of cold chain, transport and communications systems mean other immunization services take over where eradication efforts leave off. • Networks of more than 140 polio laboratories have been established. Exploited properly, these facilities are already providing a wide range of diagnostic services to identify other disease outbreaks such as measles not just polio.
Polio and the eradication of social injustice and healthcare inequities Eradication is about righting social injustice and healthcare inequity. To that end polio eradication is an important first step in the realization of every child's right to healthcare and freedom from disease. In keeping with so many other global inequities, the "last child" will probably be discovered in Africa a continent hobbled by debt and bound by strife.
Entrenching every child's right to basic healthcare – regardless of race, socio-economic status or gender – is the goal of polio eradication. The beneficiaries will be the children of warfare, want and waiting many of them helpless victims of an adult world.
Vaccines are cheap, but protection is priceless Above all, polio eradication is a model of success through partnership. The Global Polio Eradication Initiative has seen unprecedented collaboration within the UN family, public and private corporations, international organizations and NGOs that have never before participated in healthcare delivery. Both industrialized and developing countries are working together vaulting geographical, ideological and economic barriers to partner philanthropists and charitable foundations, thereby ensuring a healthier future for all children, in all nations of the world.
But nevertheless, like every other immunization initiative, polio eradication is still suffering funding shortfalls. That means inadequate resources to finish the job.
Far from drawing away services from other routine immunization programmes, polio eradication has courted and secured funding sources never before used for development or healthcare purposes (see box). The good news is that vaccines costing mere cents will protect one child from polio infection for life; $US 400-450 million could purchase global eradication. Residual funds could then be re-directed to control other infectious diseases such as HIV/AIDS, malaria and TB.
Polio Eradication: boon or bust for routine health services As with any large public and private sector undertaking, polio eradication has had its detractors. Some have questioned the impact of such targeted programmes on routine health services charging that focused eradication activities drain resources away from routine services.
In December 1999, the WHO convened a meeting to discuss the impact of targeted programmes on health systems by studying the case of the Global Polio Eradication Initiative. Delegates attending the meeting determined National Immunization Days were indeed responsible for “minor disruptions” in health care but such disturbances were nonetheless short-lived. Delegates also found that National Immunization Day planners had in fact missed opportunities to strengthen routine EPI (Expanded Programme on Immunization) programmes. In order to redress this inability, the Global Polio Eradication Initiative Strategic Plan 2001-2005 has now explicitly outlined a work programme ensuring that future polio eradication activities will add to, rather than detract from routine immunization programmes.
To date, polio eradication is the result of combined private/public partnership efforts spearheaded by WHO, Rotary International, The Centres for Disease Control (CDC), UNICEF and a variety of corporate, national and philanthropic foundations and individuals.
The two studies discussed at the 1999 WHO meeting examined both the economic and healthcare impact posed by polio eradication. The All India Institute of Medical Sciences (AIIMS) and the India Clinical Epidemiology Network (IndiaClen) supported by the United States Agency for International Development (USAID) conducted in-depth interviews with 2,159 stakeholders ranging from the prime-minister himself to individual mothers living in 24 districts in 15 of India’s 30 states.
The other study undertaken by the USAID-supported Partnerships for Health Reform (PHR) evaluated immunization financial data from the years spanning 1997–99 in Bangladesh, Cote d'Ivoire, and Morocco. Researchers hoped to investigate the impact of polio eradication activities on funding for other immunization programmes.
Ultimately, both studies concluded that despite some missed opportunities – benefits outweighed any perceived drawbacks. Researchers specifically challenged the notion that polio "mop up" activities (door-to-door immunization and surveillance activities) sucked resources away from other, equally vital, healthcare interventions. Delegates attending the WHO meeting concluded that funding for routine immunization had in fact increased in the wake of polio eradication efforts.
In Nepal for example, national immunization days constituted the very first time healthcare funds had been released directly into the various regions and districts. Governments in both Cote d’Ivoire and Morocco have increased annual expenditures for polio eradication suggesting minimal financial trade-off between eradication activities and routine immunization.
Moreover, The WHO-commissioned study uncovered no evidence suggesting polio eradication siphoned resources from other programmes. Indeed, supplementary evidence provided by WHO revealed that of the US$ 319 million in external donations earmarked for polio eradication, fully 80% was new funding not previously targeted for developing country immunization services.
According to WHO, fully 50% of polio eradication funding has come from donors who have never before contributed to healthcare services let alone development projects. Once eradication goals are finally met, this money may eventually be earmarked for other healthcare services.
Funding is not the only area where polio eradication has contributed more than it has taken away. Prior to 1999, the only large, multi-country study to examine the impact of polio eradication was the 1995 Taylor Commission, convened by the Pan American Health Organization (PAHO). This study concluded that polio eradication activities "contributed positively to overall strengthening of health systems in the Americas." Researchers based findings on interviews conducted with governments, non-governmental organizations, health staff and community groups in six countries.
The commission cited social mobilization and inter-sectoral co-operation as the top benefits of eradication activities, but also stressed polio eradication as an integral part of “systemic programmes to build health infrastructure.”
According to new studies, polio eradication has also promoted the widespread distribution of vitamin A supplements, improved co-operation between enterovirus labs and has substantially improved communication between health care workers and the community at large.
Programmers are hoping the years spanning 2001–2005, will result in strengthening routine EPI in addition to systematically building on the success of polio eradication to provide other health services.