Global Vaccines: Improving Vaccination Rates Around the World

Each year, nearly 2.5 million children die worldwide from vaccine-preventable diseases (VPDs). The millions who do survive after contracting one of these diseases often are left severely impaired. Despite the fact that vaccination rates throughout the world are at an all-time high, 21 percent of children still don’t receive them.¹ Yet, for a cost of just a few dollars per child, immunizations could be administered, millions of lives could be saved, and millions more could avoid the resulting disabilities.

U.S. Vaccination Efforts

Although the United States spends more than any other country on healthcare, the uninsured and underinsured (often represented by low-income, racial and ethnic minorities) continue to encounter barriers to receiving preventive and primary care. In turn, they suffer from some of the highest rates of disease, including obesity, cancer and AIDS. More than one in three American Indians and Hispanics and just under one in five African-Americans are uninsured, compared with one in eight Caucasians. Four in 10 low-income Americans are uninsured and about one-third of these have chronic diseases. And, while more than $2.2 trillion was spent on healthcare in 2007 alone, the gap in coverage is growing and, along with it, the incidence of disease.²

That being said, there is a positive side to immunization for America’s youth. The Centers for Disease Control and Prevention (CDC) reports that immunization rates for VPDs are high in the U.S. — about 90 percent for children between the ages of 19 months and 35 months. Fewer than 1 percent of young children fail to receive vaccinations at all.³ In fact, the majority of objectives set forth in Healthy People 2010 were met in the area of early childhood vaccinations.⁴

Also encouraging is a report that teen vaccination rates are on the rise, although slowly, particularly for the tetanusdiphtheria-acellular pertussis (Tdap) and meningococcal conjugate vaccines, according to the CDC’s National Immunization Survey. There also has been an increase in teen girls receiving their first of three doses of the human papillomavirus (HPV) vaccine. Interestingly, the rate of vaccination for HPV was statistically higher in low-income areas. And, while there is no racial or ethnic difference in girls getting one dose of the vaccine, rates are lower for African-Americans and Hispanics than for whites when it comes to receiving all three doses.⁵

Overall, the rates of vaccination levels are improving for adolescents, but progress continues to be needed. The same is true for adults. Though vaccination rates are slowly on the rise, once children reach adulthood, these rates drop. For instance, the CDC says only one-third of adults receive flu shots, only 10 percent of adults over age 60 have received the shingles vaccine, and only 17 percent of women ages 19 through 26 have received the HPV vaccine. Further, the CDC says that 95 percent of VPDs occur in adults.

Steps to Improve U.S. Vaccination Rates and Subsequent Barriers

In the late 1970s and early 1980s, major efforts were undertaken to improve vaccination rates, which at that time were extremely low — by some estimates as low as 20 percent in inner cities. The Childhood Immunization Initiative was established in 1993, which, with the help of unprecedented federal resources, increased coverage in preschool children to record high levels. So much so that in 1997, President Clinton announced that childhood vaccination goals had been exceeded.⁶

It is feared, however, that the huge successes in eradicating some diseases and significantly lessening the incidence of others through vaccinations may have put the dangers of VPDs in the back of people’s minds, therefore downplaying the necessity of receiving vaccines. “Vaccines are a victim of their own success,” says Amy Caruso, public information officer with the North Carolina Immunization Branch of the Department of Health and Human Services. “When people don’t see the impact of certain diseases, it can be easy to forget how dangerous they are. This challenge will persist as more vaccines are developed and diseases that cause sickness and death today fade from our collective memory.” Increased education on VPDs, the availability and safety of vaccines, as well as improved access all are necessary to maintain the progress made in these areas.

Initiatives to maintain vaccine awareness vigilance include the implementation of immunization information systems and electronic health records to expand the confidential, computerized population-based registries of immunizations for each patient, as well as reminder calls by providers when vaccines are due. The 2010 National Vaccine Plan includes improved communication as one of its five goals for the next decade.

Though efforts to increase vaccination rates have been successful, barriers continue to exist in some areas,resulting in part of the population failing to receive some or all of their necessary immunizations. A major barrier is the cost of vaccinations — particularly for the low-income population — which is exacerbated by the fact that private healthcare plans sometimes only partially cover vaccines and other times don’t cover them at all.

At present, each state has the option to choose whether to cover vaccinations under Medicaid. However, under the new healthcare law, Medicaid is being expanded and vaccinations are considered an “essential health benefit.” A potential loophole is that coverage of vaccinations is not required for those already enrolled in Medicaid. Other loopholes exist from state to state, such as those allowing exemptions for self-insured employer groups from providing no-cost vaccines.

Qualified adults who have Medicare Part B may receive the influenza, pneumococcal and hepatitis B vaccines (for those at medium to high risk of contraction), provided their doctor’s office accepts assignment. Other vaccinations are typically not covered under Medicare.

The new healthcare law will require all new health plans to include the cost of vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP) in full. However, Medicare will not include the full cost of vaccines, and because most vaccines fall under Medicare Part D, they may not be available in doctors’ offices. Instead, they must be prescribed, picked up at a pharmacy and returned to the physician’s office for administration, which is not recommended for a variety of reasons.

As the specifics of the healthcare law continue to be hammered out and implemented, the states are working hard in the meantime to make sure funding is readily available for immunizations. As Caruso explains: “Because immunizations are a preventive measure, the cost associated with support for immunization campaigns far outweighs the cost associated with treating the diseases vaccines prevent. The Centers for Disease Control and Prevention, which provides funding for the Vaccines for Children program, is committed to vaccines, and we feel confident that commitment will persist.”

Educational Efforts to Improve U.S. Vaccination Rates

Even though VPDs are at record low levels, it continues to be a challenge to educate the population about vaccinations. According to the Centers for Medicare and Medicaid Services (CMS), this becomes especially important for those who do not receive routine primary care. Some educational efforts include Adolescent Immunization Month, observed in April, and National Immunization Awareness Month, which is in August. Both events provide a starting point for communication between providers and patients about the importance of ensuring patient vaccines are up to date. Another effort, which some states have in place, include specific programs to educate clinicians about how to talk with patients about routine vaccinations.

More recently, novel approaches to educate the public have been launched, such as the Facebook application to “educate, motivate and mobilize people to prevent the spread of HPV.”7 Developed by the Partnership for Prevention and the University of Maryland College of Information Studies, users can take interactive quizzes, get information on prevention and anonymously share the link with friends.

Other proposals being considered include requiring adolescents who attend childcare programs, schools and colleges be vaccinated to not only limit the spread of disease, but to educate parents about the importance of immunizations. Educational materials provided to schools and clinicians offer guidance on necessary vaccines at each age level and provide talking points for providers and patients. As an example, “West Virginia is doing a lot of education and awareness raising,” says Jeffrey J. Neccuzi, director of the West Virginia Department of Health and Human Resources Division of Immunization Services. “The state’s Division of Immunization Services is conducting the 7th Grade Vaccination Initiative this 2010-11 school year in which Tdap and meningococcal vaccinations have been offered to seventh-grade students in schools across the state, not only to get seventh-grade students upto-date, but also to call attention to the need for adolescent vaccination.”

Still, even with educational efforts, the Internet is rife with misinformation that travels quickly and, in some cases, counters the good efforts of educators. Says Neccuzi: “[Our] biggest challenge has been to maintain public confidence in vaccines, while groups and individuals have been using the Internet and mass media to make sensationalized, misleading and even outright false claims concerning vaccine safety. Hopefully, the falsehood that vaccines cause autism has been debunked for good.”

Vaccines for Children: Administration in the U.S.

Started in 1994, the Vaccines for Children (VFC) program provides vaccinations at no cost to children under the age of 19 who are uninsured or underinsured through its more than 40,000 enrolled physicians. Vaccines recommended by ACIP and approved by the CDC are provided directly to providers and clinics enrolled in the program at no cost. To receive the vaccines, children must visit a Federally Qualified Health Center or Rural Health Clinic, which meet certain criteria for Medicare and Medicaid programs.

Each state or territory health department is responsible for administering its VFC program. Those eligible to receive free vaccines under the program include children who are uninsured, underinsured, Medicaid-eligible, American Indian or native Alaskan. While there is no charge for the vaccine itself because it has already been paid for by federal tax dollars, some doctors may charge an office visit or administration fee. However, should that fee be prohibitive, the fee must be waived.

The VFC program is widely accessible in the U.S. through most pediatricians, many family practice offices and those schools that have enrolled. In all, there are more than 44,000 VFC-approved locations.⁸ Thanks to VFC and the Medicaid program, it is estimated that 70 percent of children receive their vaccinations in the private medical sector.⁹

The barriers to immunizations for adolescents in the U.S. appear to be low, due in part to the VFC program. However, fewer teens are receiving recommended vaccinations, indicating room for improvement in reaching this group. Education about the importance of and access to vaccines will play a large role in making these improvements.

Worldwide Vaccination Efforts

Globally, increased access to vaccinations has saved more than 20 million children and is considered to be one of the biggest success stories in global public health. Measles and polio are two significant examples of this success. The death rate due to measles in children has declined 75 percent since the year 2000,¹⁰ while measles immunization rates have increased to 82 percent worldwide since 1990. Even the poorest regions have seen improvements in measles immunization rates: 74 percent coverage today, which is up from 56 percent in 2000. Since the implementation of the Global Polio Eradication Initiative, polio vaccine rates have increased dramatically, and the incidence of disease has been reduced from 350,000 cases in 1988 to 1,652 cases in 2008.

The United Nations’ (U.N.) Millennium Development Goal is to reduce the under-5-year-old mortality rate by two-thirds by 2013. In addition to substantial efforts by the U.N., individual nations, agencies and global nonprofits with the goal of improving global health are assisting with funding and coordination efforts. One such nonprofit, the Bill and Melinda Gates Foundation, has partnered with organizations such as the Global Alliance for Vaccines and Immunisation (GAVI), the World Health Organization (WHO), the SabinVaccine Institute, and Agence de Médecine Preventive with a goal of increasing immunization rates to 90 percent worldwide, reducing death from measles by 90 percent and eradicating polio.¹¹

Established in 1974 through a WHO Assembly resolution that promotes vaccine distribution to children worldwide, the Expanded Program on Immunization (EPI) provides immunizations to the underserved.When initiated, less than 5 percent of the world’s children had been vaccinated against six targeted diseases: diphtheria, whooping cough, tetanus, measles, poliomyelitis and tuberculosis. In the years since, additional vaccines have been added to routine infant immunization schedules, including hepatitis B, Haemophilus influenzae type b (Hib) and yellow fever. Many countries also are adding the pneumococcal conjugate and rotavirus vaccines.¹² Today, nearly 80 percent of children are vaccinated before their first birthday, thanks to partnerships between the Economic Policy Institute, UNICEF, host countries and the GAVI Alliance.¹⁰ In addition, new technologies and strategies are improving access to vaccines, including a pentavalent vaccine that allows children to be vaccinated against diphtheria, tetanus, pertussis, HepB, and Hib (DPT-HepB+Hib) all at once.

Developing countries also are learning to better understand their own health concerns. For instance, they are developing surveillance systems to determine which diseases are most prevalent and, in turn, which vaccines are most needed. And, they are raising awareness and funds, both public and private, to generate the necessary resources.

It used to take as long as 20 years for a vaccine that was available in affluent countries to become available in developing countries, but that timeline has been compressed. It is hoped that with commitment from all parties involved, including manufacturers, world partners and individual countries, that vaccines may soon be introduced simultaneously around the world.¹⁰ This is especially important now that international travel has become more accessible in many parts of the world. Vaccinating all populations will better protect every nation from disease.

Transportation Challenges to Vaccination

Aside from the high production costs of newer, more technologically advanced and often single-dose syringe vaccines, the cost of transporting vaccines to their destinations, often in the most remote areas of developing nations where infrastructure is limited, is a huge barrier to global vaccination.

One way to reduce high rates of waste from spoilage and travel/maintenance costs is to improve the 30-year-old transportation system through the use of a continuously controlled temperature environment from manufacturer to recipient. Optimize: Immunization Systems and Technologies for Tomorrow, a collaboration between WHO and PATH, a global nonprofit organization, has been tasked with formulating ideas for improving upon this supply chain. One idea being explored is the use of cooled carts (currently used to transport produce in European countries) to move vaccines from place to place in developing countries. The cost savings of using vaccine cold boxes could be considerable, because these carts are capable of handling a much larger quantity of vaccines. Optimize envisions a state-of-the-art supply chain by 2025 that meets “the changing needs of a changing world in order to enable the right vaccines to be in the right place, at the right time, in the right quantities, in the right condition, and at the right cost.”¹³

Also being explored by this collaboration are options such as incentives for manufacturing companies to make products available for developing countries, while ensuring local leaders understand the importance and value of vaccinations.

Emerging Threats to Global Vaccination

Vaccines that target diseases more prevalent in developing countries are currently in the research and development stage, including group A meningococcal meningitis (prevalent in sub-Saharan Africa), as well as a new vaccine for malaria. Yet, even as these vaccines are researched, changing pathogens result in new threats and new strains of disease. Since the 1970s, newly emerging diseases have been discovered at a rate of about one per year, according to the 2007 World Health Report. And, as our society travels more easily and readily across lands and borders, new threats are a problem for all, not just developing nations with less access to healthcare. Pockets of unvaccinated people especially become at risk for largerscale health concerns and subsequent spread of disease. New technologies in development have the potential of producing cost-effective vaccines for a variety of populations and diseases. Controlling particle size in the manufacturing process, using insect cells to express influenza proteins and create virus-like particles, and even developing a recombinant influenza vaccine technology based on combining influenza and bacteria proteins are some options being explored.¹⁴

Even as new technologies for improving the production and transportation of vaccines are discovered and introduced, many challenges remain. Funding is one of the biggest challenges because without adequate support, the momentum of these programs cannot be sustained. Additional vaccines are being developed, and these newer, more advanced vaccines are often more expensive to produce and transport via appropriate temperature-controlled environments to the most remote areas of the world. WHO and UNICEF estimate that an additional $11 billion to $15 billion will be needed to maintain the momentum with current and newly introduced vaccines to reduce VPDs by 2015.¹⁰

At the 2010 World Economic Forum, the Bill and Melinda Gates Foundation called for a “Decade of Vaccines.” Resources around the world have come together with the purpose of improving health and saving lives from illnesses caused by VPDs. And, while there is much more still to be done, the advances in just the last 20 years are astounding.