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Vaccines for Children in Low- and Middle-Income Countries

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Vaccines for Children in Low- and Middle-Income Countries Chapter 10 Vaccines for Children in Low- and Middle-Income Countries Daniel R. Feikin, Brendan Flannery, Mary J. Hamel, Meghan Stack, and Peter M. Hansen INTRODUCTION global initiatives (PHR 2014; WHO 2012a). Vaccination is central to the health goal included in the post-2015 Vaccination is the centerpiece of preventive care of Sustainable Development Goals, which is on a critical the well child. Vaccination has been one of the singular pathway to delivering on its targets. public health successes of the past half century, and its full In addition to the clear health benefits, vaccination potential remains unrealized. Pneumonia and diarrhea, has been one of the most cost-effective public health two of the leading causes of child mortality, account for interventions (Brenzel and others 2006; WHO, UNICEF, approximately 1.4 million deaths annually (Liu and others and World Bank 2002). Based on 2001 data, the cost 2016); vaccination with currently available vaccines has per death averted through routine vaccination with the potential to prevent 59 percent of pneumonia-related the six original antigens in the Expanded Program on deaths and 29 percent of diarrhea-related deaths (Fischer Immunization (EPI) was US$205 in South Asia and Sub- Walker, Munos, and Black 2013). Other leading causes of Saharan Africa; estimated cost per disability-adjusted life childhood deaths are already preventable through avail- year (DALY) averted was US$7 to US$16 (Brenzel and able and effective vaccines, such as measles and menin- others 2006). New vaccines, although more expensive, gitis, and other diseases, such as malaria, may become have also been determined to be cost-effective in Gavi- vaccine preventable in the near future (Agnandji and eligible countries (Atherly and others 2012; Sinha and others 2011; Liu and others 2012). Forecasts for vaccine others 2007) (see box 10.1). use in the 73 countries supported by Gavi, the Vaccine This chapter describes the epidemiology and burden Alliance, project that 17.7 million deaths will be averted of vaccine-preventable diseases and provides estimates in children under age five years as a result of vaccinations of the value of vaccines in health impact as well as administered from 2011 to 2020 (Lee and others 2013). broader economic benefits. The focus is on vaccination Childhood vaccination contributed greatly to prog- of infants during routine well-child visits and not on ress made toward achieving the fourth United Nations other important vaccines for older children and young Millennium Development Goal, a two-thirds reduc- adults, such as human papillomavirus vaccine, typhoid tion in childhood mortality between 1990 and 2015 vaccine, and dengue vaccines. (UN 2015), and the centerpiece of several other major Corresponding author: Daniel R. Feikin, Chief, Epidemiology Branch/Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States; [email protected]. 187 Box 10.1 Gavi, The Vaccine Alliance Disparities exist in vaccination status between coun- Advanced Market Commitment tries and within the same country, where some An innovative financing mechanism called the regions or sectors of society remain substantially Advanced Market Commitment was established undervaccinated. For example, in Nigeria’s 2008 to accelerate the introduction of and scale up the Demographic and Health Survey, the coverage of pneumococcal conjugate vaccine through Gavi the third dose of the diphtheria-tetanus-pertussis (Cernuschi and others 2011). The Advanced vaccine varied from 67 percent in the southeast to Market Commitment secured US$1.5 billion 9 percent in the northwest (NPC and ICF Macro from six donor countries and the Bill & Melinda 2009). Disparities are largely driven by socioeco- Gates Foundation, which provided a finan- nomic status; the poorest children, with the highest cial commitment to purchase pneumococcal disease burden, are the least vaccinated (Cutts, conjugate vaccine for introduction and scale-up Izurieta, and Rhoda 2013). in Gavi-supported countries at predetermined To address low coverage and inequitable access to terms. life-saving vaccines, Gavi, the Vaccine Alliance was launched in 2000 to increase access to immuniza- Eligibility and Transition to Self-Financing tion in poor countries. Gavi is a public-private part- As of January 2014, per capita gross national income nership involving the World Health Organization in 17 of 73 Gavi-supported countries had risen (WHO), the United Nations Children’s Fund, above the eligibility threshold, resulting in a five- and the World Bank; civil society organizations; year transition period during which such countries public health institutes; donors and implementing finance an increasingly larger share of their vaccines country governments; major private philanthro- each year. These countries need to mobilize domes- pists, such as the Bill & Melinda Gates Foundation; tic resources to sustainably finance their vaccines vaccine manufacturers; and the financial commu- when they complete the transition to self-financing. nity (Gavi 2013). Gavi’s support for 2011–15 has focused on 73 countries based on eligibility crite- Vaccine Investment Strategy ria determined through per capita gross national Gavi uses a vaccine investment strategy to determine income. which vaccines to add to its portfolio of support to Gavi has expanded its initial support for hepatitis B, countries every five years, taking into account the pentavalent, and yellow fever vaccines to include selection criteria and the date when different vac- measles vaccine second dose and those against pneu- cines will be available. The Gavi Board decided in mococcus, rotavirus, meningococcus serogroup A, 2014 that Gavi will undertake the following: measles- rubella, human papillomavirus, Japanese encephalitis, and inactivated polio vaccine. Gavi • Yellow fever. Increase support for additional has approved a contribution to the global cholera yellow fever campaigns. stockpile for use in epidemic and endemic settings. • Cholera. Contribute to a global vaccine stockpile From its inception through 2014, Gavi has commit- from 2014 to 2018 to increase access in outbreak ted US$8.8 billion in program support to eligible situations and further a learning agenda on its countries; 75 percent of the total commitment is for use in endemic settings. the purchase of vaccines. From 2000 through early • Malaria. Consider supporting the vaccine that is 2015, Gavi-supported vaccines have helped coun- now in development when it is licensed, WHO- tries vaccinate approximately 500 million children prequalified, and recommended for use by the through routine programs. Annex table 10A.3 shows joint meeting of the WHO Strategic Advisory the vaccine introduction status in 73 Gavi-eligible Group of Experts on Immunization and the countries. Malaria Policy Advisory Committee. box continues next page 188 Reproductive, Maternal, Newborn, and Child Health Box 10.1 (continued) • Rabies and influenza. Recommend further minimize the cost of vaccines, and ensure the assessment of the impact and operational fea- availability of quality and innovative products. sibility of supporting rabies and influenza Improved vaccine delivery strategies are needed to vaccines for pregnant women, fund an observa- ensure that immunization programs and health sys- tional study to address critical knowledge gaps tems are able to implement programs of increasing around access to rabies vaccine, and monitor size and complexity at high levels of coverage and the evolving evidence base for maternal influ- equity. It will be necessary to build on the unprece- enza vaccination. dented momentum achieved in new vaccine intro- duction and market shaping to take to scale innovative By forecasting and pooling demand from eligible approaches to generating demand for immunization; countries and purchasing large volumes of vaccines, upgrading country supply chain management systems; Gavi has created a reliable market for vaccines strengthening country health information systems; and in these settings. Gavi’s market-shaping strategy enhancing political will and country capacity related to aims to ensure adequate supply to meet demand, leadership, management, and coordination. METHODS were codified in 1984, with the goal of reaching every child with vaccines against six diseases: diphtheria, per- We describe vaccines in three categories: tussis, tetanus, measles, poliomyelitis, and tuberculosis (Hadler and others 2004; Mitchell and others 2013). The • Vaccines among the six original EPI antigens: Bacille fulcrum of the EPI program is the fixed health facility, Calmette-Guérin (BCG); diphtheria, tetanus, and where parents bring their children to be immunized. pertussis (DTP); and measles and polio The immunization visit has been expanded into the well- • Vaccines classified as new or underutilized and sup- child visit, where the contact with the health system is used ported by Gavi since its inception in 2000 to add other preventive interventions (for example, vita- • New vaccines that might be introduced into routine min A and growth monitoring). Vaccination is also deliv- immunization for infants at the well-child visit in the ered in many low- and middle-income countries (LMICs) next decade. through modes and mechanisms outside the well-child visit, such as mobile outreach clinics, supplemental immu- For the epidemiology and vaccine characteristics, nization activities as part of eradication and elimination we used a nonsystematic
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