23167 * Immunizaton aE at a glance Why is immunization The gains from additional investments in immunization of high priority? services and research and development (R & D) for new vaccines include: Immunization deserves high priority, especially in developing countries, for three main reasons: * Narrowing the burden of disease gap between the richest and poorest segments of the population; * Vaccine-preventable diseases disproportionately affect the poorest fifth of the population; * Contributing to health sector reform and development efforts; * Immunization is among the most cost-effective interventions, has had a major impact in reducing * Savings of $1.5 billion annually from completing the burden of disease, and the benefits are public the eradication of polio; goods; and g Substantial reduction in the burden cf disease by * Newer vaccines, and those under development, making effective under-used vaccines widely have the potential to prevent diseases, e.g., available, e.g., vaccines against Hepatitis B, tuberculosis, malaria, and human immunodeficiency Haemophilus influenzae type b, and yellow fever; virus (HIV), that currently cause an enormous burden of disease. i Reducing the burden of disease from conditions such as Vitamin A and iodine deficiencies, by Communicable diseases, many of which are vaccine- expanding the coverage of these interventions as preventable, account for 77% of the mortality gap components in immunization services, in countries and 79% of the disability-adjusted life years (DALY) where they are highly prevalent. gap, between the world's poorest and richest 20%. Immunization is acknowledged to be among the most The Expanded Programme on Immunization (EPI), cost-effective and highest-impact health interventions, targeting mainly six communicable diseases of preventing 2-3 million deaths annually, and even childhood, reduced the share of these six diseases in more illness and disability. the total burden of disease among children under five from about 23% in the mid-I 970s, to less than 10% Smallpox eradication saves as many as five million in 2000. To fully immunize a child against the six lives annually, and is arguably public health's diseases costs about US$17, making immunization greatest achievement. one of the most affordable interventions available. Most vaccines cost under US$50 per DALY gained. Vaccines are currently preventing about five million deaths each year but there are still three million Malaria, tuberculosis, and HIV are responsible for deaths a year from diseases that could be prevented more than five million deaths each year, and all are by existing vaccines. potentially preventable by vaccines. Rapid scientific progress suggests that an effective vaccine is likely to be available for at least one of these diseases in the next decade. March 2001 What to do about Immunization The table below summarizes the core immunization interventions, the intended beneficiaries, and key indicators to track achievement of objectives Reduce vaccine-preventable disease and disability Prevent six communicable The EPI package of vaccines against diphtheria, Children under five and / Reduction in vaccine-preventable deaths diseases of childhood as well tetanus, pertussis (whooping cough), polio, measles, women in the / % of children under 1 2 months fully immunized for as tetanus in adulthood, tuberculosis, and Hepatitis B reproductive age group DTP including maternal tetanus / % of children under 1 2 months immunized for The EPI immunization schedule is: measles / Birth - BCG (TB), OPV-0 (polio) V % of districts that have achieved 80% covcrage / 6 weeks - DTP-1 (diphtheria, tetanus and pertussis), OPV-1, Hep B-1 / 10 weeks - DTP-2, OPV-2, Hep B-2 / 14 weeks - DTP-3, OPV-3, Hep B-3 / 9 months - Measles / Women of reproductive age - 2 doses tetanus toxoid Prevent other selected dis- Introduce or scale up under-used vaccines, such as Target groups vary ac- V % of target group immunized against each eases, where they are causing those against Hepatitis B, Hoemophilus influenzae cording to the epidemio- selected disease a large disease burden type b, and yellow fever logical situation and program implementation capacity: usually infants for Hepatitis B and for Haemophilus influenzoe type b, and people of all age groups living in countries at risk for yellow fever Reduce vaccine-preventable Include vitamin A supplements with routine immuniza- Susceptible groups, / % of children, 6-59 months, receiving vitamin diseases and major associated tion visits where this deficiency is prevalent: for post- especially young chil- A supplements conditions partum mothers (within 60 days of birth) and twice dren and post-partum / prevalence of night-blindness in the population yearly for children 6-59 months; vitamin A can be women (symptom of vitamin A deficiency) added to mass immunization campaigns (such as polio NIDs, measles campaigns, Child Health Days, etc.) Give high-dose treatment for clinical signs of vitamin A deficiency and other severe health prob- lems (see Nutrition at a glance) Simplified assessment of national immunization services The following questions are intended to provide a 9. Do the MOH staff responsible for immunization quick overview of national immunization systems. services at district-level receive training and Answers to the questions should be readily available refresher training regularly (i.e., does the MOH from the Ministry of Health (MOH) or World Health have a human resources development strategy for Organization (WHO). A "no" answer to any question immunization services)? indicates that corrective action is needed (including World Bank support). Disease prevention/control Infrastructure I10. Is the country on track to achieve polio eradication? 1. Is there an individual in the MOH designated with responsibility and authority to achieve 11. Is the surveillance system functioning well (e.g., immunization system goals? standard case definition in use, at least 80% completeness of reporting from established 2. Is there a multi-year plan of action for the reporting sites, and feedback information being immunization services specifying both vaccine provided by the central levels to peripheral levels coverage and disease reduction goals? on system performance)? 3. Is there a line item in the MOH budget to support Introduction of new vaccines the immunization services? 112. Do estimates of the disease burden for Hepatitis B, yellow fever, and Haemophilus influenzae type . Are the immunization services reaching at least b exist or are there plans to carry out disease 80% of children nation-wide? bude stdis burden studies? 5. Is the vaccine used of assured quality (e.g., 1 3. Does the multi-year immunization plan include a procured from a pre-qualified source or through plan and funding for introducing new vaccines? UNICEF, or regulated by an independent and fully functional National Regulatory Authority)? 6. Has an injection practices assessment ever been conducted? If so, have the findings led to changes in policy (e.g., WHO-UNICEF-UNFPA joint policy statement WHO/V&B/99.25 on the use of auto-disable syringes in immunization services and the gradual phasing out of standard disposable and sterilizable syringes)? 7. Is the vaccine management system adequate (e.g., stock management, cold chain, wastage, use of vaccine vial monitors and other indicators)? 8. Are opportunities to integrate other health interventions (such as vitamin A) with immunization services, being used effectively? Do's and don'ts in national Resources ready to help with immunization systems: immunization projects * DO take advantage of the potential of immuniza- U World Bank Regional Immunization focal points tion to strengthen and reform the health system, (Africa-Christy Hanson; EAP-Enis Baris; ECA- e.g., by facilitating decentralization, and Nedim Jaganjac; LAC-Ruth Levine; MENA- strengthening surveillance systems, and DONh Maryse Pierre-Louis; SAR-Benjamin Loevinsohn) make it a vertical program. and the Anchor (Amie Batson), who can make • DO focus on strengthening routine immunization, available technical information, technical but DON'T forget that supplementary immunization assistance, and funds for studies and project campaigns are important to mobilize communities preparation and achieve certain accelerated disease control * GAVI: Amie Batson (Financing Task Force co-chair), initiatives of international importance. Laura Cooley (Advocacy Task Force) or Tony • DO take advantage of the high degree of national Measham (Country Coordination Task Force) for and international collaboration and ownership of contacts and resources immunization as a good model for overall health * Bank-financed immunization projects recommended sector development. for adaptation in other settings: the FY1999 Bolivia * DON'T forget that NGOs and the private sector Health Sector Reform project, and the FY2000 are key participants in immunization coalitions: for India Immunization Strengthening project social mobilization, in public-private partnerships for vaccine R & D, and for giving immunizations. Key web sites • DON'T assume that vaccines for developing countries will be developed, marketed, and used, * GAVI: www.vaccinealliance.org without a major international effort, like the one * The Bill and Melinda Gates Children's Vaccine pioneered by WHO and UNICEF, and being Program at PATH: www.ChildrensVaccine.org extended by the Global Alliance for Vaccines and * WHO: www.who.int/vaccines Immunization (GAVI). * Centers for Disease Control and Prevention: * DO remember the importance of high quality immunization coverage data, now a key indicator w B www.wordNk a for Poverty Reduction Strategy Papers (PRSPs), and an important component of debt relief (HIPC) efforts. Key references * DO remember that a continuous supply of vaccines of assured quality is essential. * S.A. Plotkin, Orenstein, W.A., eds. Vaccines, Third * oNfI forge halt manageials, edition. W.B. Saunders, Philadelphia, 1999. Dfor exmpe, toa maintainrt cold cain, il U A.R. Hinman, "Eradication of vaccine-preventable for example, to maintain the cold chain, supervise diseases", in Fielding, J., ed, Annual Review of staff, plan resource mobilization, etc. disealth, 20Fi 11ng29, 1999w E DO seek opportunities for immunization to be Public Health, 20:2 1P1-229, 1999. discussed in the macro-policy dialogue with William Foege "The Power of Immunization", in governments, and in World Bank country The Progress of Nations, 2000, UNICEF, New assistance strategies; this helps to extend York, pp 19-21. discussions to finance and planning ministries WHO,VProduc I a S which play a key role in financial sustainability. WHO/V&B/00. 1 3 a DO take advantage of the fact that immunization is 'WHO, Safety of injection: WHO-UNICEF-UNFPA one of the interventions in the Integrated Joint Statement on the vse of auto-disable syringes Management of Childhood Illness (IMCI package). in immunization services, WHO/V&B/99.25 v DO remember the importance of reliable surveil- a Integrating Vitamin A with Immunization: An lance to assess the overall impact of immunization Information and Training Package (A CD-ROM systems and to identify outbreaks, areas of high- produced by WHO and Helen Keller International, risk, and/or weak system performance. 2000) Expanded versions of the "at a glance" series, with e-linkages to resources and more information, are available on the World Bank Health-Nutrition-Population web site: www.worldbank.org/hnp