Global Immunization through the Lens of Development

Supporting global immunization programs is a profound way to control disease and improve the lives of many, particularly in the developing world. In 1974, the World Health Organization (WHO) created the Expanded Programme on Immunization (EPI), a worldwide effort mobilized to help countries increase immunization coverage of basic childhood vaccines—diphtheria, measles, pertussis, polio, tetanus, and tuberculosis—using the third dose of diphtheria, tetanus, and pertussis (DTP3) as a measure of progress. Building on the historical success of smallpox eradication, the WHO sought to increase global vaccination coverage (which was <5% in 1974) among children younger than one year of age. However, one-fifth of the world's children, especially those who live in low-income countries, are not fully vaccinated with these traditional vaccines during their first year of life.¹

The Global Vaccine Action Plan (GVAP) for 2011–2020 has established immunization coverage targets of at least 90% DTP3 coverage nationally and at least 80% DTP3 coverage in every district.² Countries can take a variety of actions to attain these targets, depending on their needs and the current status of their health system and immunization program.

This year, on the 40th anniversary of EPI, through the collective work of many partners, we are witnessing a time of unprecedented support and commitment to ending preventable child and maternal deaths within a generation, a top priority of the U.S. Agency for International Development (USAID). In this Decade of Vaccines,² we join global efforts to extend the full benefits of immunization to all people, regardless of where they are born, who they are, or where they live. And USAID continues its long-standing partnership with the U.S. Department of Health and Human Services (HHS) and other actors on the global stage. Our work as a development agency contributes to global efforts outlined in this report by the National Vaccine Advisory Committee (NVAC) Global Immunizations Working Group, “Enhancing the Work of the Department of Health and Human Services National Vaccine Program in Global Immunization: Recommendations of the National Vaccine Advisory Committee.”³ The challenges and recommendations in the report highlight holistic approaches to technical and financial investments in health as well as increased coordination among the partnership of actors. We support these efforts, particularly through a developmental lens, emphasizing support to national governments toward investing in health, immunization programs, and human and institutional resources.

A DEVELOPMENT APPROACH

USAID's long-standing strategy provides technical assistance to countries and the global technical community by focusing on improving the efficiency and equity of EPI worldwide. Central to USAID's work is supporting countries through a development lens—an approach largely centered on long-term investments in addressing weaknesses within the health sector. Health programs also intersect other domains of development, layering on top of social, economic, and environmental objectives toward fulfilling country needs. USAID and other donor investments across the development spectrum (e.g., democracy, governance, and education) affect the sustainability and infrastructure of immunization programs. Reaching into these other domains is important for influencing the proximate determinants of health and poor outcomes.

We know vaccines are cost-effective interventions and that immunization programs save lives, improve the health of children and communities, and lead to healthier, more productive people. We also know that for programs to be sustained, they must operate successfully within country-specific cultural, social, and economic circumstances. The development context underpins USAID's approach to building capacity and capability to work in sustainable ways, particularly given the country resources available. The provision of accessible, country-financed, quality primary health care, with immunizations as a cornerstone of such a system, is central to prospects for genuine human development. Although primary and vertical health programs coexist, USAID uses a systems approach to strengthen immunization as an integral part of the broader health system. Moreover, the functionality of immunization as part of an overall primary health-care system requires the recognition and need to enhance the integration of sound technical interventions with socioeconomic development programs, including training of human resources for health to achieve sustained success.⁴

A BRIEF LOOK AT USAID

As part of a worldwide effort undertaken by the WHO in 1966 to eradicate smallpox, USAID entered into the global immunization arena supporting a large regional project in Africa to control measles and eradicate smallpox. Investments in the development of a jet gun injector accelerated smallpox eradication by advancing the use of new technology for mass immunization campaigns. USAID support for smallpox and measles elimination marked an initial foray into what would be a long history in supporting global immunization. In 1985, USAID launched the Technology and Resources for Child Health (REACH) project, its first major global project in support of childhood immunization services. Since then, USAID has continuously supported immunization programs at the national and sub-national levels and worked to scale up evidence-based, equitable, locally adapted solutions with country partners.⁵ Our technical assistance in immunization continues to be deliberately designed to respond to local needs and circumstances. Grounded in close collaboration with national Ministries of Health and district health teams, USAID invests in a process of joint identification of problems and priorities and negotiates strategies to address these challenges, balancing the need for results with the directive to build local capacity in line with USAID's developmental mandate. Other field contributions include groundbreaking clinical field research on the efficacy of pneumococcal vaccine and improved methods for addressing behavioral and social determinants of vaccine utilization.

We have made essential and globally important contributions to polio eradication beginning early on in the global polio eradication efforts. USAID-provided support beginning in 1988 was geared toward efforts by the Pan American Health Organization (PAHO) to strengthen routine immunization systems, control and eventually eliminate measles, and rid the region of polio. In 1996, we expanded our polio investments globally to extend to the other WHO regions of the world—Africa, Southeast Asia, Eastern Mediterranean, Europe, and the Western Pacific—providing technical assistance to improve all aspects of implementing and monitoring polio campaigns and supporting surveillance and communication activities as part of the global eradication effort. Since 2000, USAID has also been a central and strategic partner in the GAVI Alliance (GAVI). To date, USAID has provided more than $1 billion in financial support to GAVI, primarily to purchase vaccines in low-income countries. Our U.S. government contribution to GAVI expands access to life-saving vaccines by shortening the time from when a vaccine becomes licensed for use to when it is introduced into immunization programs in GAVI-eligible countries, closing the inequity gap between the industrialized and developing world.

Past USAID investments in technologies have led to products that now reach millions of people, including safe injection technologies such as the SoloShot^TM syringe, which is automatically disabled after one use and cannot be refilled or reused, thereby preventing the transmission of bloodborne diseases from needle reuse. USAID also supported UniJect^TM—a combined needle and syringe prefilled with vaccine that can also only be used once—which has been used for childhood vaccination. These prefilled syringes can have practical field advantages for use in hard-to-reach geographic communities. Perhaps most widely used is the small label that is affixed to vaccine containers, changing color to indicate that the vial has been exposed to heat outside the recommended temperature range indicated for storage. These vaccine vial monitors, which were developed by USAID in response to field needs, have transformed the way we deliver vaccines and have helped to increase the effectiveness and coverage of national immunization programs worldwide.⁶

USAID: PART OF THE U.S. GOVERNMENT FABRIC

As with other U.S. government agencies, including the Department of Agriculture and Department of Defense, USAID's role and mission clearly differs from that of HHS. As the foreign assistance arm of the federal government, USAID functions as a development partner with technical capability in a broad range of domains, including health. For more than three decades, USAID has contributed to the canvas of public and private collaboration that comprises the vaccine and immunization enterprise.

We stand at a point where we must invest diligently and thoughtfully in host country capacity and in routine immunization systems. Immunization programs are cornerstones of health systems—a public good that virtually all governments rely upon to safeguard the health of their populations. Achieving and sustaining high and equitable coverage is needed to end deaths from vaccine-preventable diseases. To reach this goal, we must work together to invest in creative approaches to recognize families and communities as partners with the health system; support the managerial capability needed at the national, district, and facility levels to strengthen routine immunization; and support the needs of countries to address their challenges and weaknesses.

Our collective U.S. government contribution to global health is significant, and our investments capitalize on technological advances that enable the development and delivery of vaccines for diseases once considered beyond the reach of biomedicine. As we enter the 40th anniversary of EPI, the global community celebrates the success of a system for immunization service delivery, management, and program monitoring that is able to reach even the most peripheral parts and marginalized communities in countries around the world. We look strategically forward to the future as USAID, together with partners, works to end preventable child death by 2035.