Immunisations fall in developing countries

Posted: 9 January 2001

Author: John Donnelly

A three-decade effort to protect children and adults in the developing world by vaccinating them against six killer diseases is quietly losing momentum. Only 10 years after UNICEF declared victory in reaching its goal of immunizing 80 per cent of vulnerable populations around the world, many sub-Saharan countries have fallen below 50 per cent coverage; in three the rate is less than 31 per cent. In parts of India and elsewhere, the situation is scarcely better.

The low rates translate into the deaths of an estimated 3 million people a year, most of them children, from diseases that can be prevented by vaccines costing about US$1.50 per person, according to the World Health Organization.

The reasons for the slippage include wars, the explosion of cases of HIV and AIDS in Africa, and waning interest among international donors. Governments and agencies have slashed funding for immunization campaigns since 1990 because they believed the job was done, according to scores of public health specialists.

Expecting that developing countries would pay for most immunizations themselves, donors shifted their funds to other efforts, including health structure changes and the goal of eradicating polio. UNICEF cut back immunization funding from $182 million in 1990, when it accounted for 57 per cent of its spending on health, to $51.5 million in 1998, just 25 per cent of health expenditures.

Cuts

The US Agency for International Development also cut money for basic immunization against six diseases - diphtheria, measles, pertussis (whooping cough), polio, tetanus, and tuberculosis. It cut funding from an average of $51 million a year in the early 1990s to $47 million in 1998, according to an analysis by the US General Accounting Office. But the impact on overall immunization was much more drastic than this number suggests, since roughly half of the money in 1998 was earmarked for polio alone.

"I believe what has happened to immunization coverage may be the greatest public health tragedy of our generation," said Ron O'Connor, chief executive officer of Management Sciences for Health in Boston, which received a $29 million grant from the Bill and Melinda Gates Foundation in September 2000 to start pilot projects to rebuild health care services. "For children to die of illnesses we can fix is really unconscionable."

And yet the problems have received scant public attention. When Microsoft's founder, Bill Gates, donated $750 million a year ago toward delivering and producing new vaccines for the developing countries, there was no thought about putting money into rebuilding the infrastructure needed to deliver vaccination services, such as transportation and refrigeration. Child being Immunised© Giacomo Pirozzi/UNICEFBut early this year, after several veteran public health specialists joined the Gates' Children's Vaccine Program, the charity decided to expand into rebuilding decaying vaccination services.

Delivery systems

"We have to look at the needs of developing an AIDS vaccine, a tuberculosis and malaria vaccine, but even if we had those vaccines tomorrow, we would have great difficulty in delivering them," said Mark A. Kane, programme director. "So we decided we should be building the systems to deliver them once those vaccines come in."

The programme estimates that 30 million of the 130 million children born each year are not vaccinated. "To this day, you can go into ministries of finance in developing countries and say, 'We need to pay a lot of attention to routine immunization,' and they look surprised," Kane said.

In many rural towns and urban slums, routine immunization levels have fallen dramatically in recent years, even as the global average has risen slightly to 82 per cent.

Dramatic falls

For example, Nigeria's overall coverage fell from 80 per cent in 1990 to 27 per cent in 1998; the Democratic Republic of Congo went from 46 per cent to 25 per cent; Togo went from 100 per cent to 54 per cent; and the Central African Republic fell from 93 per cent to 53 per cent.

The problem isn't limited to Africa. For instance, in the Indian state of Uttar Pradesh, overall coverage fell from 90 per cent in 1990 to 30 per cent in 1998. Immunizations against individual diseases such as measles, which kills an estimated 900,000 children a year, mostly in Africa, have also plummeted. Measles coverage remained stagnant or declined in 32 of the world's 44 poorest countries since 1990, according to a recent study by Robert Steinglass and Rebecca Fields of BASICS, a global child survival project. Fully half of all African children were not immunized against measles in 1999, they found. That was 10 years after the World Health Assembly announced a goal of reducing deaths from measles by 95 per cent.

The greatest public health success since the end of World War II is arguably the eradication of smallpox, which was completed in 1979. Polio eradication could be another success, with health specialists estimating eradication in five years. And despite the backsliding of the past 10 years, the situation remains far better than in 1972, when only an estimated 5 per cent of the world's population was immunized against the six diseases.

Hepatitis and HiB

Under the Gates initiative, overseen by the year-old Global Alliance for Vaccines and Immunizations, the goal is to introduce vaccines against Hepatitis B and Haemophilus influenzae type B (or HiB, a bacterial disease unrelated to flu that can cause meningitis and pneumonia) throughout the Third World's 74 countries.

Those two vaccines are routinely given in rich countries, and rarely in the developing world. The result is that an estimated 400,000 children die each year of HiB infection. Despite the low cost of the vaccine, poor countries have not purchased it.

The Children's Vaccination Program hopes to deliver these two new vaccines to all poor countries in the next five years. To receive the money, countries must submit detailed plans for distributing the vaccines as well as agree to pay for them after the five-year period. The first $150 million was given recently to 13 countries.

While public health specialists uniformly praise the initiative, most doubt that it alone can dramatically improve routine immunization coverage over the long term.

Jeffrey Sachs, an international economist at Harvard University and chairman of the Commission on Macroeconomics and Health of the World Health Organization, said that Gates's huge donation was seed money. "It's not a year or two of help that we need, but it's 20 years of help," Sachs said. "What Gates has done is fantastic. But Gates by himself can't carry the world on this."

"What we need," Sachs said, "is to get the pump primed for massive amounts of donations from the industrialized countries."

Source: The Boston Globe

Related links:

  • Children's Vaccine Programme

  • Unicef - Facts for Life:Immunisation

  • Global Alliance for Vaccines and Immunisation.