Evidence Brief

HPV Vaccines: New Momentum in Eliminating Cervical Cancer

Group of girls laughing
Posted on by stacy

In August of 2020, the World Health Assembly adopted the global strategy to accelerate the elimination of cervical cancer as a public health problem. Vaccines against the human papillomavirus (HPV) can prevent the vast majority of the world’s 570,000 annual cases of cervical cancer. Increasing access to the HPV vaccine, as well as screening and treatment, for women and girls living in low- and middle-income countries is an important step for global gender equity, potentially leading to the elimination of cervical cancer within the next 100 years.

HPV Vaccination is a Critical Step Towards Cervical Cancer Elimination

Human papillomavirus (HPV) is a vaccine-preventable infection that causes nearly all cases of cervical cancer. According to the Global Cancer Observatory1, infection with HPV led to an estimated 570,000 cases of cervical cancer and 311,000 cervical cancer deaths worldwide just in 2018.

The overwhelming majority of women impacted by this preventable cancer live in low- and middle-income countries (LMIC). According to a 2020 study2 from The Lancet Global Health, “Approximately 84% of all cervical cancers and 88% of all deaths caused by cervical cancer occurred in lower-resource countries.” Across many regions of Africa, cervical cancer caused by HPV is the leading cause of cancer-related deaths among women.

In August 2020, a global strategy to accelerate the elimination of cervical cancer as a public health problem was adopted by the Member States of the World Health Organization (WHO).

WHO recommends the following targets or milestones that each country should meet by 2030 to be on track to eliminate cervical cancer within the century:

  • 90% of girls fully vaccinated with the HPV vaccine by the age of 15;
  • 70% of women screened using a high-performance test by the age of 35, and again by the age of 45; and
  • 90% of women identified with cervical disease receive treatment.

The results of a 2020 analysis3 from Brisson et al. found that just by meeting HPV vaccination targets, cervical cancer cases could drop by 89% within a century in the 78 countries worst affected by the disease. Meeting targets for cervical cancer screening and treatment would further reduce cervical cancer cases by 97%, averting 72 million cervical cancer cases over the next century.

VIEW-hub: Mapping HPV Vaccine Progress

VIEW-hub is an interactive mapping platform for visualizing up-to-date data on vaccine use and impact. In 2020, VIEW-hub launched a new module on HPV vaccination providing users with updated maps and data tables to track country-level progress for rollout of vaccines.

Through VIEW-hub, users can access and download immunization advocacy resources including global data downloads, maps and country profiles.  For HPV vaccination, VIEW-hub provides data on current program types, current/planned vaccine product, current dosing schedule, current or planned distribution sites and target populations by sex.

Broad Benefits of HPV Vaccine

While HPV is most commonly associated with cervical cancer, this viral infection also can cause a number of other cancers in both men and women. These other cancers include anal, vulvar, vaginal, penile, and head and neck cancers.

Currently, three vaccines are available which offer varying levels of protection against HPV-associated cancers. The vaccines all contain protein particles without live virus but they differ in the number of viral subtypes that are included.  Bivalent (2 subtypes) and quadrivalent (4 subtypes) vaccines are prequalified by the WHO and the third option is a nonavalent (9 subtypes) vaccine that is primarily available in high-income countries. All three vaccines include HPV genotypes 16 and 18, which account for about 70% of cervical cancer cases worldwide. The quadrivalent and nonavalent vaccines further protect by preventing infection with HPV genotypes 6 and 11 which cause anogenital warts. The nonavalent vaccine offers the highest level of protection by including an additional five HPV genotypes.

Enhancing Global Equity for Women and Girls

The vast majority of women and girls who have been protected by receiving an HPV vaccine are based in high-income countries, while the most vulnerable populations with the highest burden in terms of cervical cancer incidence and mortality remain largely unprotected in low-resource settings.

  • Only 1% of the 118 million women and girls included in HPV vaccine programs between 2006 and 2014 were from low- or lower-middle-income countries, according to an analysis from 20164.
  • High initial prices for HPV vaccines have limited access for women in low-income countries: high-income countries comprise only 14% of cervical cancer cases, but almost 70% of women receiving HPV vaccines4.
  • Women from low- and middle-income countries can also face compounded health risks due to high burdens of HIV: rates of cervical cancer are estimated to be four to five times higher among women who are living with HIV compared to HIV-negative women, according to a 2016 UNAIDS report5.

Economic Impacts and Cost-Effectiveness

High prices have been cited as a major barrier limiting HPV vaccine access. Countries that face the greatest challenges in financing HPV vaccines often may have the most to gain from implementing these valuable vaccination programs.

  • A 2016 health economics analysis6 of return on investment for vaccines in 94 low- and middle-income countries estimated that HPV vaccines would yield a 3-fold return on investment between 2011 and 2020.
  • A 2020 cost-effectiveness analysis7 using the PRIME (Papillomavirus Rapid Interface for Modelling and Economics) tool found that “HPV vaccination provides greater health benefits and is more cost-effective than was previously estimated” and recommended, “The WHO African region is expected to gain the greatest health benefits and should be prioritised for HPV vaccination.”
  • A 2020 proof-of-concept health economics framework8 described how HPV vaccination could lead to increased labor participation and economic output, potentially enhancing gender equity for women. “The improvements in economic productivity from years of employment gained by female workers could be approximately $4.7 million in Tanzania, $24 million in India, and $18 million in the United Kingdom (in US$2015).”

Overcoming Low Knowledge and Awareness of HPV Vaccination

One obstacle to increased uptake of HPV vaccination in LMICs is limited public knowledge about cervical cancer, HPV, and the benefits of HPV immunization. Despite current low levels of knowledge about the HPV vaccine, several studies have reported high acceptability and a willingness among women and girls to receive the vaccine for themselves or their daughters.

  • In Bangladesh, a 2018 study9 among ever-married women showed that even with low knowledge of cervical cancer or HPV vaccine, more than 90% of women were willing to receive the HPV vaccine themselves or to have their daughters receive it.
  • In Mozambique, a 2018 study10 among school-aged girls found that while only 33% had heard of HPV, 91% were willing to receive the vaccine.
  • In Haiti, a 2017 study11 presented similar findings from adult women over age 18. Only 27% had heard of HPV and 10% knew of the HPV vaccine but 96% were willing to vaccinate their daughters once they learned about the purpose of the vaccine.
  • Several systematic reviews focused on African and Asian populations have also found that even when knowledge about HPV and the HPV vaccine is low, acceptability of the vaccine was often high. A 2014 systematic review12 of HPV vaccine acceptability in Africa found that across 14 unique studies, acceptability of the HPV vaccine for daughters ranged from 59–100%.

Successful HPV Vaccine Delivery Campaigns

Several key obstacles limit HPV vaccine expansion efforts including inadequate health system capacity, inconsistent vaccine supply, lack of general knowledge about the vaccines, and unique implementation challenges associated with vaccinating older children and adolescents. Innovative approaches for delivering the vaccine to girls in the target age range have shown some promise to advance HPV vaccination.

  • In 2010, Bhutan13 became the first low- or middle-income country to implement a national HPV vaccination program through a school-based delivery model. This program achieved coverage between 90% and 99% in the target populations of school-aged girls.
  • Rwanda’s national HPV vaccination program14 is another example of a successful school-based rollout. This school-based delivery approach was so successful that it was able to obtain 93% coverage among girls in grade six based on completion of a three-dose series.
  • Despite potential gains though successful school-based vaccination programs, it is also important to ensure equitable access to HPV vaccination for girls who are not currently enrolled in or attending school. Girls who represent hard-to-reach populations may be more vulnerable and at higher risk of HPV infection and cervical cancer, particularly if they are human immunodeficiency virus (HIV) positive15.
WHO Resource – HPV Vaccine Introduction Clearing House
WHO Resource – Scaling-Up HPV Vaccine Introduction (PDF)
WHO Resource – Introducing HPV Vaccine into National Immunization Programmes (PDF)

Meeting Unprecedented Demand

Despite cost barriers, high demand for HPV vaccines in 2018 led to a supply shortage of HPV vaccine due to, “the unprecedented uptake of HPV support in Gavi-eligible countries, combined with increased global demand for HPV vaccines from higher-income countries.”

In June 2020, Gavi announced that five manufacturers were committing to the prioritization of HPV vaccine supply to support Gavi-supported countries.  This commitment will ideally increase the affordability and promote accessibility of the vaccine.

Gavi’s most recent estimate is that up to 84 million girls in the world’s poorest countries could have access to HPV vaccine over the next 5 years which would advance public health by preventing 1.4 million cases of cervical cancer deaths worldwide.

References

  1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians. 2018;68(6):394-424. doi:10.3322/caac.21492
  2. Arbyn M, Weiderpass E, Bruni L, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. The Lancet Global Health. 2020;8(2):e191-e203. doi:10.1016/S2214-109X(19)30482-6
  3. Brisson M, Kim JJ, Canfell K, et al. Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income countries. The Lancet. 2020;395(10224):575-590. doi:10.1016/S0140-6736(20)30068-4
  4. Bruni L, Diaz M, Barrionuevo-Rosas L, et al. Global estimates of human papillomavirus vaccination coverage by region and income level: a pooled analysis. The Lancet Global Health. 2016;4(7):e453-e463. doi:10.1016/S2214-109X(16)30099-7
  5. HPV, HIV and Cervical Cancer: Leveraging Synergies to Save Women’s Lives. UNAIDS; 2016. https://www.unaids.org/en/resources/documents/2016/HPV-HIV-cervical-cancer
  6. Ozawa S, Clark S, Portnoy A, Grewal S, Brenzel L, Walker DG. Return On Investment From Childhood Immunization In Low- And Middle-Income Countries, 2011–20. Health Affairs. 2016;35(2):199-207. doi:10.1377/hlthaff.2015.1086
  7. Abbas KM, van Zandvoort K, Brisson M, Jit M. Effects of updated demography, disability weights, and cervical cancer burden on estimates of human papillomavirus vaccination impact at the global, regional, and national levels: a PRIME modelling study. The Lancet Global Health. 2020;8(4):e536-e544. doi:10.1016/S2214-109X(20)30022-X
  8. Portnoy A, Clark S, Ozawa S, Jit M. The impact of vaccination on gender equity: conceptual framework and human papillomavirus (HPV) vaccine case study. Int J Equity Health. 2020;19(1):10. doi:10.1186/s12939-019-1090-3
  9. Islam JY, Khatun F, Alam A, et al. Knowledge of cervical cancer and HPV vaccine in Bangladeshi women: a population based, cross-sectional study. BMC Women’s Health. 2018;18(1):15. doi:10.1186/s12905-018-0510-7
  10. Bardají A, Mindu C, Augusto OJ, et al. Awareness of cervical cancer and willingness to be vaccinated against human papillomavirus in Mozambican adolescent girls. Papillomavirus Research. 2018;5:156-162. doi:10.1016/j.pvr.2018.04.004
  11. Gichane MW, Calo WA, McCarthy SH, Walmer KA, Boggan JC, Brewer NT. Human Papillomavirus Awareness in Haiti: Preparing for a National HPV Vaccination Program. Journal of Pediatric and Adolescent Gynecology. 2017;30(1):96-101. doi:10.1016/j.jpag.2016.07.003
  12. Cunningham MS, Davison C, Aronson KJ. HPV vaccine acceptability in Africa: A systematic review. Preventive Medicine. 2014;69:274-279. doi:10.1016/j.ypmed.2014.08.035
  13. Dorji T, Tshomo U, Phuntsho S, et al. Introduction of a National HPV vaccination program into Bhutan. Vaccine. 2015;33(31):3726-3730. doi:10.1016/j.vaccine.2015.05.078
  14. Binagwaho A, Wagner C, Gatera M, Karema C, Nutt C, Ngaboa F. Achieving high coverage in Rwanda’s national human papillomavirus vaccination programme. Bull World Health Org. 2012;90(8):623-628. doi:10.2471/BLT.11.097253
  15. Scaling-up HPV Vaccine Introduction. World Health Organization; 2016. Accessed August 20, 2020. https://apps.who.int/iris/bitstream/handle/10665/251909/9789241511544-eng.pdf?sequence=1

Equity and Immunization: Shrinking the Gaps

Posted on by stacy

Although more children than at any point in history are now protected against vaccine-preventable diseases, millions of zero-dose children are still missing out on the life-saving benefits of immunization entirely. These children often live in the world’s most marginalized communities where inequities are clustered and compounded by poverty, geography, gender, and conflict. In order to keep making progress against preventable deaths and illness, leaders will need to integrate equity across global, national, and sub-national immunization strategies.

Key Messages

  • Health inequities are “the unjust differences in health between persons of different social groups, and can be linked to forms of disadvantage such as poverty, discrimination and lack of access to services or goods,” as defined in the WHO Handbook on Health Inequality Monitoring.
  • Both between and within countries, vaccine coverage is often distributed unequally across populations – those in the highest socioeconomic status groups and those with the most education often have the highest immunization rates while marginalized populations, those living in poverty, and those with lower education have the least access to immunization.
  • Improving equitable access to vaccines aligns with achieving the Sustainable Development Goals.
  • Prioritizing equity requires multisectoral strategies designed to reach communities that have previously been excluded from access to health services based on geography, educational status, and sociocultural group.

Compounded Vulnerability

Record numbers of children are protected from preventable illnesses thanks to immunization, yet millions of children, often the poorest and most vulnerable, continue to be left behind. Vaccine-preventable diseases disproportionately affect those who experience both poor overall health and low economic standing; the children who miss out on life-saving vaccines are often those in the poorest households and the most remote locations, and whose families lack access to clean water, education, and adequate nutrition.

Over 13 million ‘zero-dose’ children have never received any vaccines at all, based on a 2019 analysis from UNICEF. These children and their families already experience a disproportionate burden of vaccine-preventable illnesses like measles, diphtheria, and polio. With life-saving immunization services around the world disrupted by the COVID-19 pandemic, these children are at even great risk from disastrous outbreaks of vaccine-preventable illnesses.

On June 4th, 2020 the Global Vaccine Summit will aim to raise at least $7.4 billion for Gavi, the Vaccine Alliance. This funding will help support the mass vaccination campaigns and rebuilding of health systems needed over the coming years to help address the damage done by the COVID-19 pandemic. Gavi’s strategic plan for 2021-2025 prioritizes immunization equity and the need to reach the communities that have missed out on previous immunization efforts, especially those most marginalized by poverty, geography, and conflict.

Combating inequities in health and wealth through immunization

Evidence has shown that vaccines have the greatest health and economic benefit amongst the poor. Globally, the poorest populations often experience the worst impacts of vaccine-preventable diseases, both in terms of health burdens in illness and death as well as carrying potentially crushing costs associated with medical care, missed work, and lasting disability.

Research shows that vaccines are one tool that can help break the pernicious cycle of poverty and ill health, improving equity across both health and wealth. By preventing disease, vaccination also prevents the costs associated with medical treatment and thus helps to reduce the likelihood that households will fall into or remain in poverty.

  • A 2018 modeling study of the economic impact of 10 childhood immunizations in 41 low- and middle-income countries found that with the lowest income households received the greatest financial risk protection from costs of measles, pneumococcal disease, and rotavirus. The authors conclude that: “Including equity components into economic evaluations will allow policy makers to opt for interventions that target specifically the most vulnerable populations.”
  • A 2015 study from Ethiopia looking at the impact of pneumococcal vaccine introduction in Ethiopia found that 30-40% of all deaths averted would be expected to occur in the poorest wealth quintile. The greatest resulting financial risk protection would also be concentrated among the lowest income quintile.
  • A 2018 cost-effectiveness analysis found that expanding rotavirus vaccination coverage among the poorest and most vulnerable populations of children would substantially increase the overall impact of rotavirus immunization in Pakistan; children in the poorest households would experience a three to four times greater mortality reduction benefit compared to children in the richest households.

Empowering and educating women can lead to greater rates of vaccination among children

Although girls and boys are immunized at similar rates globally, barriers that inhibit women’s ability to access healthcare and immunizations for their children may still exist at subnational levels and across different populations. Research in several LMIC contexts has found that access to education, particularly for women and girls, is often strongly associated with higher rates of immunization in children.

Graph
Figure 1. Brinda, E.M., Rajkumar, A.P. & Enemark, U. Association between gender inequality index and child mortality rates: a cross-national study of 138 countries. BMC Public Health 15, 97 (2015). https://doi.org/10.1186/s12889-015-1449-3
  • A 2015 ecological study of 138 countries found that greater gender inequality was significantly correlated with lower immunization coverage and higher neonatal, infant, and under-5 mortality.
  • A 2018 study in Nigeria found a robust association with maternal education and immunization coverage for children at both the individual and at the community levels. The researchers concluded that maternal education had a spillover effect that benefited immunization rates of all community members, not only a mother’s own children. This suggests that even children of uneducated mothers can benefit from the education of women in the community overall.
  • A 2017 systematic analysis of equity in vaccine coverage across 45 low- and middle-income countries found that maternal education is a strong predictor of child vaccine coverage. Children of the least educated mothers were 55% less likely to have received measles vaccine and three doses of DTP vaccine compared to children of the most educated mothers.
  • A 2015 review of health equity and disparities data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys conducted in 70 developing countries found that “with respect to immunization, the greatest disparity exists for children born to women with no education compared with those born to women with secondary (or higher) education.” The global coverage of the third dose of DTP is 26% higher among children born to mothers with some secondary education compared to mothers with no education.

Geography and Sociocultural inequities and the immunization gap

Where a child is born often dictates their access to health resources like vaccines. Despite improvements in vaccination rates at the national level, local level disparities continue to persist. This means that children born in remote, rural, or urban slum settings may have significantly less access to immunization compared to their peers born in urbanized settings near health facilities. Inequities also exist for marginalized populations and minority groups who may have restricted access to health services such as immunizations. Conflict and migration are additional factors that threaten access to immunization for many children and their families.

These inequities in vaccination rates—often concealed in national averages—call for special efforts to improve immunization rates in this rapidly growing sub-population to reduce both health inequities and the risk of infectious disease outbreaks in the wider society.

Restrepo-Méndez, María Clara, Barros, Aluísio JD, Wong, Kerry LM, Johnson, Hope L, Pariyo, George. et al. (‎2016)‎. Inequalities in full immunization coverage: Trends in low- and middle-income countries. Bulletin of the World Health Organization, 94 (‎11)‎, 794 – 805B. World Health Organization. http://dx.doi.org/10.2471/BLT.15.162172
  • A 2015 immunization equity review found that globally, coverage of the third dose of DTP among 1-year-olds is 8% higher among urban dwellers compared to children living in rural environments.
  • Children from families that have migrated from other parts of the country have less access to health services and lower vaccination rates compared to the general population. According to a 2016 systematic review and meta-analysis, children who are rural-urban migrants in China, India, and Nigeria were less likely to be fully immunized by the age of one year than non-migrant urban residents and the general population.
  • A 2019 study in New Zealand found that the use of pneumonia conjugate vaccines (PCV) appears associated with reductions in ethnic and socioeconomic disparities in invasive pneumococcal disease (IPD), all-cause pneumonia (ACP), and otitis media hospitalization among Māori and Pacific children. Following the introduction of conjugate vaccines in the country, Maori and Pacific children’s rates of admission for IPD dropped by 79% and 67%, respectively.
  • A 2019 study examining immunization rates in urban and rural populations in Tanzania found that wealth and mother’s education were significant predictors of vaccination rates in both urban and rural settings. However, low paternal education, lack of antenatal care, and home births were significantly associated with low vaccination rates only in rural settings, suggesting a need for tailored vaccine programs.
  • The results of a 2016 cross-sectional polio serosurvey found that the Jordan Ministry of Health’s proactive campaign to locate and vaccinate high-risk populations has been successful in maintaining high population immunity—even with a recent influx of refugees from Syria. The study included a community sample of 479 children under 5 years old living in areas of Jordan identified as high risk due to being hard-to-reach, having high numbers of refugees, and lower vaccine coverage (under 90%).

Maternal Immunization: Protected Together

Pregnant Woman leaning against the wall
Posted on by stacy

Maternal immunization is a promising strategy for protecting mothers, the developing fetus, and young infants during a particularly vulnerable time in their lives – especially in low- and middle-income countries where morbidity and mortality among women and their children is high. During pregnancy, vaccines allow antibodies from the mother to cross into the placenta, protecting moms and their babies from life-threatening illnesses.

Key Messages

  1. Maternal immunization is an important strategy for protecting infants and newborns in the vulnerable period before they can receive their own vaccinations.
  2. Providing high-value antenatal care (ANC) during pregnancy can include vaccination against diseases like influenza, pertussis, and tetanus—which can help set both mother and baby up to survive and thrive.
  3. Complications from vaccine-preventable infections during pregnancy and early infancy can have cascading health and economic effects on individuals, families, communities, and health systems.
  4. Maternal immunization offers a critical opportunity to elevate maternal and newborn health on the broader health and development agenda and catalyze progress toward Sustainable Development Goal (SDG) 3.

Maternal Immunization: The Window of Vulnerability

Because newborn babies are too young to receive most vaccines, they are unprotected against many pathogens that can cause severe infections leading to hospitalization, long-term health problems, or death. Maternal immunization provides an important opportunity to protect the unborn child, the newborn, and in many cases, the mother, from preventable illnesses.

Providing vaccines during pregnancy not only boosts the mother’s immunity against dangerous pathogens, but a mother’s antibodies can be passed to her unborn baby in-utero through the placenta or through breast milk. For newborn babies, these maternal antibodies provide essential protection during a “window of vulnerability” when infants are too young to get their own immunizations.

Lackritz EM, Stepanchak M, Stergachis A. Maternal immunization safety monitoring in low- and middle-income countries: a roadmap for program development. Bill & Melinda Gates Foundation and Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), 2017.

The Neonatal Period is Critical for Child Survival

Even one preventable child death is too many. Analysis by the WHO shows that the first 28 days of life for a baby – also called the neonatal period – is when a child’s survival is most threatened. Based on 2018 estimates, around 2.5 million neonates die in their first month of life, annually around the world.

A 2015 report from the Bill and Melinda Gates Foundation assessed opportunities for maternal immunization in resource-limited settings, estimating that more than half of neonatal deaths in the first month of life are associated with infections (22%). When that infection is vaccine-preventable, maternal immunization can help protect mothers, the unborn fetus, and infants during this vulnerable window.

Child mortality rates have fallen dramatically, but the progress has not been even across all child ages 

Maternal Immunization Can Prevent Severe, Costly Adverse Health Outcomes

Several studies have found that pregnant women and infants under 6 months are at increased risk of severe illness from infectious diseases such as influenza and pertussis that can lead to hospitalization or admission to intensive care units.

  • In a large U.S. study1, infants born to mothers who reported receiving influenza vaccination during pregnancy had an 81% lower chance of being hospitalized with influenza compared to infants whose mothers did not receive influenza immunization.
  • A 2017 study2 in the U.S. found that vaccinating women with Tdap during the third trimester of pregnancy provided 81% protection against pertussis to infants <2 months and 91% protection against hospitalization for pertussis.
  • A 2018 analysis3 of data from Nepal, Mali, and South Africa found evidence that maternal influenza immunization may reduce severe pneumonia episodes among infants <6 months. Overall, the incidence rate of severe pneumonia was 20% lower in infants in the maternal immunization group compared with the control group, although this rate varied by country.

Strengthening Maternal and Child Health Equity

Globally, 2017 data show that over 800 women die every day due to preventable causes related to pregnancy and childbirth. These deaths are inequitably distributed: the vast majority of maternal deaths (94%) occur in low-resource settings and overwhelmingly impact the poorest and most vulnerable populations, communities of women and children with the most limited access to routine health care.

Many of the same barriers that prevent women from receiving or seeking care during pregnancy and childbirth are the same barriers that prevent their children from accessing life-saving vaccinations:

  • Poverty
  • Distance to facilities
  • Lack of information
  • Inadequate and poor-quality services
  • Cultural beliefs and practices
https://data.unicef.org/topic/child-survival/neonatal-mortality/

Immunization as a Gateway to Maternal Health Services

Since it was established in 1974, the Expanded Program on Immunization (EPI) now reaches 85% of children globally with life-saving vaccines. With its strong service delivery infrastructure, immunization can provide a gateway to help connect women and their families with additional health services. A 2019 WHO Maternal Immunization and Antenatal Care Situation Analysis (MIACSA) Project report suggests that integration of immunization with other antenatal services is a promising strategy that can lead to “increased coverage, improved system efficiency, improved user satisfaction and increased demand.”

EPI’s strong delivery system has the potential to integrate additional reproductive, maternal, neonatal, and child health interventions with immunization. A 2013 knowledge summary describes how with thoughtful and measured planning, non-vaccine health interventions can be integrated with immunization visits to create a “programme foundation through which broad services can be equitably provided as well as give a beneficial boost to EPI coverage.”

Mothers who Use Maternal Health Services are More Likely to Have Fully Immunized Children

UNICEF reports that an estimated 86% of pregnant women globally have some form of antenatal care contact with a skilled health provider at least once in their pregnancy. However, current WHO guidance is that women receive eight or more contacts for antenatal care over the course of a pregnancy. For many women, particularly those in LMICs, pregnancy may be the first time a woman has contact with formal health services. Several studies across different countries have found that access to maternal health services is also associated with higher rates of immunization in children.

  • In Pakistan4, women who had 3 or 4 antenatal care contacts had children who were 40-60% more likely to receive all required vaccines on time compared to children whose mothers made only 1 or 2 ANC visits.
  • A 2019 Nigerian study5 found that ANC attendance, skilled birth attendance, and postnatal care were significantly associated with a woman’s child being fully immunized irrespective of socio-economic status, geopolitical zone, place of residence, parity, person who decides on mother’s healthcare and mother’s age. This finding is consistent with studies in Senegal, Bangladesh, Indonesia, India, and Zimbabwe, which showed that a mother’s ANC attendance was significantly associated with full immunization of her children.
  • A 2019 study6 of basic vaccine coverage of children in Myanmar found that those born to mothers who received tetanus vaccination during pregnancy were three times more likely to have completed their recommended vaccinations by age two compared to children of mothers who did not receive tetanus toxoid vaccination.

The Maternal Neonatal Tetanus Elimination program has been cited as proof of concept for the feasibility and potential for maternal immunization to reduce neonatal mortality particularly in LMICs (Krishnaswamy, S., Lambach, P., & Giles, M. L., 2019)

A Good Investment: Cost-effectiveness of Maternal Immunization

The cost-effectiveness of different maternal immunization strategies varies by country, context, and health priorities. Several studies examining the cost-effectiveness of maternal immunization have found that it can be cost-effective, depending on a variety of factors.

  • Brazil has experienced a significant increase in pertussis incidence since 2011 which has particularly affected infants <4 months of age. A 2016 cost-effectiveness analysis7 found that introducing universal maternal vaccination with Tdap into the National Immunization Program in Brazil could be a cost-effective intervention. However, a 2020 cost-effectiveness analysis8 concluded that universal adult immunization of Tdap would not be cost-effective.
  • Several analyses in high-income countries have found that maternal immunization for pertussis can be cost-effective. A 2018 study9 in Japan concluded cost-effectiveness could be reached even if only 50% of pregnant women received the vaccine. A 2016 study10 in the United States suggests that maternal immunization for pertussis is cost-effective compared to other adult vaccination strategies for preventing infection in infants too young to be vaccinated (postpartum vaccination, vaccination of a second parent, or untargeted vaccination of comparably aged adults).
  • A 2016 analysis11 estimated that in Mozambique almost 18,000 neonatal tetanus cases could be prevented annually if pregnant women had better geographic access to a health facility offering tetanus toxoid vaccine. Reducing vaccine-preventable cases of neonatal tetanus could save the country an estimated $183,931,229–$522,248,480 in annual treatment costs and productivity losses.

The Future of Maternal Immunization

There are promising new maternal vaccines in development for two major causes of infant deaths that disproportionately impact those living in LMICs: Group B streptococcus (GBS) and respiratory syncytial disease (RSV).

Group B Streptococcus is a bacterial infection that causes an estimated 150,000 preventable stillbirths and infant deaths worldwide every year. A 2017 journal article12 estimates that GBS “is an important component of the worldwide burden of 2.6 million stillbirths,” accounting for an estimated 4% of stillbirths in sub-Saharan Africa. No licensed vaccines currently exist against GBS, but work is underway to develop a vaccine that can be given to pregnant women so that newborns are protected even before birth.

RSV can be deadly for infants, particularly those living in LMICs. It’s estimated that RSV causes 1.4 million hospitalizations in the first 6 months of life and 120,000 deaths before five years of age worldwide each year. Currently, the treatments available for RSV are limited but several vaccines are in development.

References

  1. Shakib, J. H., Korgenski, K., Presson, A. P., Sheng, X., Varner, M. W., Pavia, A. T., & Byington, C. L. (2016). Influenza in infants born to women vaccinated during pregnancy. Pediatrics, 137(6). https://doi.org/10.1542/peds.2015-2360
  2. Skoff, T. H., Blain, A. E., Watt, J., Scherzinger, K., McMahon, M., Zansky, S. M., Kudish, K., Cieslak, P. R., Lewis, M., Shang, N., & Martin, S. W. (2017). Impact of the us maternal tetanus, diphtheria, and acellular pertussis vaccination program on preventing pertussis in infants <2 months of age: A case-control evaluation. Clinical Infectious Diseases, 65(12), 1977–1983. https://doi.org/10.1093/cid/cix724
  3. Omer, S. B., Clark, D. R., Aqil, A. R., Tapia, M. D., Nunes, M. C., Kozuki, N., Steinhoff, M. C., Madhi, S. A., Wairagkar, N., & for BMGF Supported Maternal Influenza Immunization Trials Investigators Group. (2018). Maternal influenza immunization and prevention of severe clinical pneumonia in young infants: Analysis of randomized controlled trials conducted in Nepal, Mali and South Africa. The Pediatric Infectious Disease Journal, 37(5), 436–440. https://doi.org/10.1097/INF.0000000000001914
  4. Noh, J.-W., Kim, Y., Akram, N., Yoo, K.-B., Park, J., Cheon, J., Kwon, Y. D., & Stekelenburg, J. (2018). Factors affecting complete and timely childhood immunization coverage in Sindh, Pakistan; A secondary analysis of cross-sectional survey data. PLOS ONE, 13(10), e0206766. https://doi.org/10.1371/journal.pone.0206766
  5. Anichukwu, O. I., & Asamoah, B. O. (2019). The impact of maternal health care utilisation on routine immunisation coverage of children in Nigeria: A cross-sectional study. BMJ Open, 9(6), e026324. https://doi.org/10.1136/bmjopen-2018-026324
  6. Nozaki, I., Hachiya, M., & Kitamura, T. (2019). Factors influencing basic vaccination coverage in Myanmar: Secondary analysis of 2015 Myanmar demographic and health survey data. BMC Public Health, 19(1), 242. https://doi.org/10.1186/s12889-019-6548-0
  7. Sartori, A. M. C., de Soárez, P. C., Fernandes, E. G., Gryninger, L. C. F., Viscondi, J. Y. K., & Novaes, H. M. D. (2016). Cost-effectiveness analysis of universal maternal immunization with tetanus-diphtheria-acellular pertussis (Tdap) vaccine in Brazil. Vaccine, 34(13), 1531–1539. https://doi.org/10.1016/j.vaccine.2016.02.026
  8. Fernandes, E. G., Sartori, A. M. C., de Soárez, P. C., Amaku, M., de Azevedo Neto, R. S., & Novaes, H. M. D. (2020). Cost-effectiveness analysis of universal adult immunization with tetanus-diphtheria-acellular pertussis vaccine (Tdap) versus current practice in Brazil. Vaccine, 38(1), 46–53. https://doi.org/10.1016/j.vaccine.2019.09.100
  9. Hoshi, S., Seposo, X., Okubo, I., & Kondo, M. (2018). Cost-effectiveness analysis of pertussis vaccination during pregnancy in Japan. Vaccine, 36(34), 5133–5140. https://doi.org/10.1016/j.vaccine.2018.07.026
  10. Atkins, K. E., Fitzpatrick, M. C., Galvani, A. P., & Townsend, J. P. (2016). Cost-Effectiveness of Pertussis Vaccination During Pregnancy in the United States. American Journal of Epidemiology, 183(12), 1159–1170. https://doi.org/10.1093/aje/kwv347
  11. Haidari, L. A., Brown, S. T., Constenla, D., Zenkov, E., Ferguson, M., de Broucker, G., Ozawa, S., Clark, S., & Lee, B. Y. (2016). The economic value of increasing geospatial access to tetanus toxoid immunization in Mozambique. Vaccine, 34(35), 4161–4165. https://doi.org/10.1016/j.vaccine.2016.06.065
  12. Seale, Anna C, Hannah Blencowe, Fiorella Bianchi-Jassir, Nicholas Embleton, Quique Bassat, Jaume Ordi, Clara Menéndez, et al. “Stillbirth with Group b Streptococcus Disease Worldwide: Systematic Review and Meta-Analyses.” Clinical Infectious Diseases 65, no. suppl_2 (November 6, 2017): S125–32. https://doi.org/10.1093/cid/cix585.

Possibilities: The Far-Reaching Benefits of Immunization

Nurse preparing Immunization
Posted on by stacy

The story of immunization is often headlined with the remarkable health benefits—millions of lives saved, and illnesses and hospitalizations prevented. But the true impact of vaccination is even more far-reaching, touching many areas of people’s lives from supporting early childhood growth and development to improving educational outcomes and productivity, promoting economic stability, and helping to address equity gaps: It’s seemingly impossible to undersell the importance of vaccination.

This World Immunization Week, the VoICE editors highlight some of the broader benefits of immunization—not only helping to prevent illness and save lives, but also promoting healthy development, productivity, economic stability, and equity for all.

Key Messages

  1. Only looking at the direct impact of vaccination on morbidity and mortality grossly underestimates the wider value of vaccination on overall health and development
  2. Several studies show that immunization has the potential to increase productivity by averting preventable illness
  3. Vaccines are associated with improved cognitive ability, education, and healthy physical development – which translates into increased economic productivity
  4. Vaccine-preventable diseases disproportionately affect the poorest children and families, but immunization can be a cost-effective tool to improve equity across geographies, gender, and marginalized populations

Preventing Pandemics Supports Economic Stability

The global health community is now facing an unprecedented challenge in the COVID-19 pandemic. As countries across the world attempt to slow the virus’s spread, this event has become a potent reminder of the vital importance of vaccination; we are seeing today just how much an infectious disease outbreak can ravage both national and global economies. Vaccines are important tools to help avert potentially catastrophic health costs that arise from preventable infectious disease outbreaks. Several studies have found that vaccines can bring additional stability to national economies by preventing the high costs incurred by illnesses.

  • A 2009 study in Africa found an economic loss of US $43-72 million resulting from the 110,837 cases of cholera reported in 20071.
  • Researchers modeling the costs of potential pandemic influenza in the UK estimated costs of illness between £8.4 and £72.3 billion depending on the severity of the fatality rate, and even larger still for an extreme pandemic. In such a scenario, vaccination could limit the overall economic impact of pandemics2.
Quote

Vaccines Help Promote Productivity

 Productivity—the measure of output by a working individual or a population—is an important determinant of standard of living. By preventing illness, vaccination can help promote productivity by supporting healthy cognitive development and success in school, ultimately helping children achieve their full potential across the lifespan.

  • A 2019 longitudinal study followed almost 6,000 children in India, Ethiopia, and Vietnam throughout childhood, finding that those vaccinated against measles scored better on cognitive tests of language development, math, and reading compared to children who did not receive measles vaccines3.
  • In a 2011 study in the Philippines, children vaccinated against six diseases performed significantly better on verbal reasoning, math and language tests than unvaccinated children4.
  • Vaccine-preventable diseases lead to both work and school absenteeism, which can negatively impact productivity and cause a substantial economic burden. A Norwegian study found that children hospitalized with rotavirus were absent from daycare for 6.3 days, on average, and 73% of their parents missed work5.

Vaccines Support Healthy Child Growth and Development

Some vaccine-preventable diseases can delay or interrupt normal growth and development in early childhood, leading to long-lasting damage that can adversely impact children for the rest of their lives. Persistent or recurrent infections in early life can lead to poor growth and stunting, which in turn can adversely affect adult health, cognitive capacity, and economic productivity.

  • Childhood vaccination programs can be a tool for mitigating undernutrition in developing countries. Children enrolled in Universal Immunization Programs observe improvements in terms of age-appropriate height and weight as per results of a study focused on 4-year-old children in India. On average, height and weight deficits were reduced by 22-25% and 15% respectively6.
  • A study in Kenya revealed that polio, BCG, DPT and measles immunization had protective effects with respect to stunting in children. In children under the age of 2 years, children immunized with polio, BCG, DPT, and measles vaccines were 27% less likely to experience stunting compared to unimmunized children7.
  • A 2013 study conducted in several developing countries found that children with moderate-to-severe diarrhea grew significantly less in length in the two months following an episode of illness compared to age- and gender-matched controls8.
  • Modeling of data from India’s 2005-2006 National Family Health Survey indicated that vaccinations against DPT, polio, and measles were significant positive predictors of a child’s height, weight, and hemoglobin concentration. Such indicators, in turn, influence children’s cognitive development and hence the future supply of skilled labor that is critical for economic growth9.

Tackling Immunization Inequities Can Have Substantial Benefits

While huge progress has been made in introducing and scaling up access to important vaccines, we still have a long way to go. There is significant evidence of inequities in vaccine coverage that exists between and within countries, as well as between and within different populations. In Gavi-supported countries, there are still an estimated 10.4 million “zero-dose children” who have not received any doses of DTP-containing vaccine.

  • Results of a 2019 study in Kenya found that immunization outreach for remote or hard-to-reach populations can still be highly cost-effective. The study found that failure to vaccinate hard-to-reach children against measles would result in more than 1,400 measles cases, 257 deaths, and cost nearly U.S. $10 million over the course of 4 years, mainly due to productivity losses from caretakers missing work10.
  • A 2018 study found that children of poor labor migrants living in Delhi, India are much less likely to be fully vaccinated than the general population and thus are at greater risk of vaccine-preventable diseases. Only 31% – 53% of children from migrant families were fully immunized (against 7 diseases) by 12 months of age, compared to 72% in the overall population of Delhi — with recent migrants having the lowest rates11.
  • Researchers looking at vaccination coverage in 45 low- and middle-income countries found that maternal education is a strong predictor of vaccine coverage. Children of the least educated mothers are 55% less likely to have received measles-containing vaccine and three doses of DTP vaccine than children of the most educated mothers12.

The evidence shows that vaccines offer cross-cutting benefits for individuals, families, communities, and truly everyone across the globe. Cross-disciplinary research from many global health perspectives demonstrates that vaccines as a versatile, impactful tool that does so much more than just preventing millions of deaths and illness every year: Vaccines benefit global economies, boost productivity, and help close gaps in equity.

As we respond to COVID-19, the reality that infectious disease outbreaks anywhere in the world can quickly become a threat anywhere further highlights the importance of investment in vaccination as a part of strong, resilient health systems. As countries across the world grapple with containing the COVID-19 outbreak, we must also work together to ensure that the world’s most vulnerable children don’t miss out on the vaccines that prevent devastating illnesses like measles, polio, diarrhea, and pneumonia. In the face of this current challenge, it’s essential that we work together to protect essential health services like immunization to ensure that all people have a shot at living a healthy life protected from preventable disease.

Visit the VoICE World Immunization Week 2020 Social Media Toolkit for messaging and images to promote the broad benefits of vaccines. The toolkit is also available on the official World Immunization Week 2020 website.

References

  1. Kirigia, J.M., Gambo, L.G., Yolouide, A., et al 2009. Economic burden of cholera in the WHO African Region. BMC International Health and Human Rights. 9(8). doi: 10.1186/1472-698X-9-8
  2. Smith, R.D., Keogh-Brown, M.R., Barnett, T., et al 2009. The economy-wide impact of pandemic influenza on the UK: a computable general equilibrium modeling experiment. BMJ. 339. https://doi.org/10.1136/bmj.b4571
  3. Nandi A, Shet A, Behrman JR, et al. 2019. Anthropometric, cognitive, and schooling benefits of measles vaccination: Longitudinal cohort analysis in Ethiopia, India, and Vietnam. Vaccine. 37. https://doi.org/10.1016/j.vaccine.2019.06.025
  4. Bloom, D. E., Canning, D., & Shenoy, E. S. (2011). The effect of vaccination on children’s physical and cognitive development in the Philippines. Applied Economics, 44(21), 2777-2783. https://doi.org/10.1080/00036846.2011.566203
  5. Edwards CH, Bekkewold T, Flem E. 2017. Lost workdays and healthcare use before and after hospital visits due to rotavirus and other gastroenteritis among young children in Norway. Vaccine. 35. https://doi.org/10.1016/j.vaccine.2017.05.037
  6. Anekwe, T.D., Kumar, S. 2012. The effect of a vaccination program on child anthropometry: Evidence from India’s Universal Immunization Program. Journal of Public Health. 34(4). https://doi.org/10.1093/pubmed/fds032
  7. Gewa, C.A. and Yandell, N. 2011. Undernutrition among Kenyan children: contribution of child, maternal and household factors. Public Health Nutrition. 15(6). https://doi.org/10.1017/S136898001100245X
  8. Kotloff, K.L., Nataro, J.P., Blackwelder, W.C., et al 2013. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study. Lancet. 382(9888). https://doi.org/10.1016/S0140-6736(13)60844-2
  9. Bhargava, A., Guntupalli, A.M., Lokshin, M. 2011. Health Care Utilization, socioeconomic factors and child health in India. Journal of Biosocial Sciences. 43(6). https://doi.org/10.1017/S0021932011000241
  10. Lee BY, Brown ST, Haidari LA et al. 2019. Economic value of vaccinating geographically hard-to-reach populations with measles vaccine: a modeling application in Kenya. Vaccine. 37(17). https://doi.org/10.1016/j.vaccine.2019.03.007
  11. Kusuma YS, Kaushal S, Sundari AB, et al. 2018. Access to childhood immunization services and its determinants among recent and settled migrants in Delhi, India. Public Health. 158. https://doi.org/10.1016/j.puhe.2018.03.006
  12. Arsenault, C., Harper, S., Nandi, A., et al. 2017. Monitoring equity in vaccination coverage: A systematic analysis of demographic and health surveys from 45 Gavi-supported countries. Vaccine. 5(6). https://doi.org/10.1016/j.vaccine.2016.12.041

World Immunization Week 2020 Social Media Toolkit

VoIce banner for World Immunization Week 2020
Posted on by stacy

World Immunization Week 2020 (April 24-30) is an opportunity for immunization advocates across the world to promote the value of vaccines for protecting people of all ages against preventable diseases. Our VoICE social media toolkit provides messaging on the vital role that vaccines play in global health. Beyond saving millions of lives every year #VaccinesWork For All by strengthening our health care systems, protecting global health security, shrinking equity gaps, and more.

Join us in promoting the message that #VaccinesWork For All by sharing the evidence on the broad benefits of immunization!

VoICE Social Media Toolkit for World Immunization Week 2020

Download the VoICE World Immunization Week 2020 Toolkit for a series of social media messages and shareable images that highlight key evidence on the value of vaccines! Messaging covers the six main topics of the VoICE Compendium: Health, Education, Economics, Equity, Health Systems and Integration, and Global Issues.

The toolkit is also available as a downloadable PDF and all images can be easily copied or saved directly from this page.

Welcome to WIW 2020!

Immunization saves millions of lives every year. Yet, there are still nearly 20 million children worldwide who are not getting the vaccines they need.

We have it in our power to close this gap!

Welcome to World Immunization Week banner

#VACCINESWORK TO PROTECT OUR HEALTH

#DYK those with HIV, cancer, and weakened immune systems benefit from immunization of others through herd immunity?

https://bit.ly/immunization_HerdEffects

Herd Effects Children banner

#VaccinesWork for all by protecting people around us, especially those who are vulnerable like new babies, older adults, and people who are seriously ill.

http://bit.ly/CancerandImmunization

Herd Effects All Ages banner 2

Malnourished kids suffer the most from pneumonia, diarrhea and other vaccine-preventable infections.

It’s time to level the playing field!

Bit.ly/2OqdS7C

Undernutrition cycle

#VACCINESWORK TO IMPROVE EDUCATION

#DYK that immunization is linked to improved education and cognitive outcomes? Immunized children stay healthier so they miss less school and attain higher school grades.

https://bit.ly/VoICE_Education

#VACCINESWORK TO IMPROVE EDUCATION banner

#VACCINESWORK FOR ECONOMIES

Vaccines don’t just save lives; they keep the world’s most vulnerable people out of poverty. A 2018 @Health_Affairs study found the poorest households receive the most benefit from increased access to vaccines.

bit.ly/3a35ORd

Policy Poverty Quote

Studies show that vaccines can help stop poverty in addition to saving lives. Read the latest research on the economic benefits of vaccines.

#VaccinesWork for All

bit.ly/2MGAJui

Prevent Poverty banner

#VACCINESWORK FOR EQUITY

13.5 million children around the world still can’t access vaccines – these children are often the most vulnerable to disease and health disparities. We have it in our power to close this gap!

Leaving no child behind means ensuring the most marginalized – those touched by conflict or forced from their homes – have access to lifesaving #vaccines.

bit.ly/voice_migration

Vaccines are a tool for reducing gender, geographic, and sociocultural inequity – find the latest evidence on immunization and equity on VoICE:

http://bit.ly/2ILpP

https://bit.ly/34gn848

https://bit.ly/2Vzlx5p

Immunization For Equity

#VACCINESWORK FOR HEALTH SYSTEMS

Immunization can decrease hospital admissions, thus alleviating pressure on overburdened health systems, freeing up needed medical resources.

https://bit.ly/2V4H9Ye

In Kenya, rates of pneumonia hospitalizations in children <5 dropped by 27% after 4 years of PCV10. #VaccinesWork for All to reduce hospital admissions and free up more resources to treat and prevent other illnesses.

bit.ly/2V4H9Ye

#VACCINESWORK FOR HEALTH SECURITY

Between 2005-2014 nearly 400 infectious disease outbreaks (excluding measles) were reported to the @WHO, threatening the health security of the entire world.

View @Voice_Evidence’s feature issue on #outbreaks to learn more: http://bit.ly/voice_outbreaks

Immunization Outbreaks banner

2019 saw a record for measles outbreaks – more than 140,000 lives were lost, mostly children.

Measles is so contagious that the exposure of a single person without immunity to the virus can spark an outbreak that quickly burns through whole communities.

http://bit.ly/voice_outbreaks

Special edition: Pneumococcal conjugate vaccines in the global fight against child pneumonia

Mother holdes her child in Nepal
Posted on by stacy

Pneumonia is responsible for more than 800,000 under-5 deaths each year—claiming a child’s life every 39 seconds. Vaccines against pneumococcus, Haemophilus influenzae type b (Hib), pertussis, measles, and influenza are important to help protect children from disease and prevent the lasting health, equity, and socioeconomic effects of pneumonia. This week, country leaders, scientific experts, program and policy officials, and advocates from around the world will meet in Barcelona to elevate pneumonia on national and global health agendas and raise the call for action against this common, serious, preventable cause of child illness and death.

Key Messages

  1. Pneumonia remains a leading killer of children under 5 worldwide, disproportionately affecting the poorest children with lasting effects
  2. Immunization is a key part of a comprehensive approach to prevent and control childhood pneumonia, along with interventions like breastfeeding, handwashing, reducing indoor air pollution, and appropriate treatment
  3. Vaccines that help protect against pneumonia have even broader benefits, like helping to avert potentially catastrophic medical costs that can push families into poverty
  4. This week’s Global Forum on Childhood Pneumonia calls for global action to set practical, evidence-based plans to end preventable child pneumonia deaths

The Global Forum on Childhood Pneumonia

For three days this week, Barcelona will host hundreds of country leaders, scientific experts, program and policy officials, and advocates as they raise awareness of the global burden of child pneumonia, recognize progress made, and call for commitments to concrete strategies to prevent and control this leading cause of child death. Fighting for Breath: The Global Forum on Childhood Pneumonia serves as a call to action to deliver concrete measures to save children from the disease that claims more than 800,000 young lives each year.

To do this, we need action grounded in evidence—to recognize the importance of a comprehensive approach to pneumonia prevention and control, including the broad, lasting benefits of immunization. Vaccines against causes of pneumonia, like pneumococcal conjugate vaccines (PCV), are vital parts of this strategy and can help protect children from disease and prevent the lasting health, equity, and socioeconomic effects of pneumonia.

Three things to know about the benefits of PCV

1. Pneumonia is the leading infectious cause of death in children under 5 years of age, and disproportionately affects the poorest children across the world, impacting their health, growth, and development. Pneumococcus is a common bacterial cause of pneumonia, which makes PCV a valuable tool to prevent disease, promote health, and fight poverty by preventing medical costs-related impoverishment, interrupting the cycle of infections, and helping to improve growth.

Stay tuned! New evidence on the cost of pneumonia and value of pneumococcal vaccines will be presented at the Global Forum.

2. Use of PCV (among other vaccines) has been shown to reduce health care costs and need for treatments like antibiotics by preventing or reducing the severity of vaccine-preventable disease. This in turn reduces individual health care expenditures, the burden on health systems, and the development of antibiotic and multi-drug resistance.

3. PCV and other vaccines can also help improve health equity, especially when immunization programs reach those who have less access to health services. These populations are often at highest risk for vaccine-preventable diseases and related complications, and include those who are poor, malnourished or immunocompromised, HIV positive, and other marginalized populations and minority groups.

Progress in PCV products and prices

Following on Gavi’s success in achieving lower prices for Hib-containing pentavalent vaccine, another vaccine for childhood pneumonia and meningitis, market-shaping success has also been achieved for PCV. For Gavi-eligible countries, PCV prices have been steadily declining and new multi-dose presentations that help reduce cold chain requirements and price per dose are now available. This is the third straight year that Pfizer has reduced the price of PCV for developing countries, now down to US$2.90.

The PCV product landscape continues to expand—a new pneumococcal conjugate vaccine is here! PNEUMOSIL® is a 10-valent PCV developed by Serum Institute of India, Pvt., Ltd. and PATH, with funding from the Bill & Melinda Gates Foundation. It is now WHO-prequalified and will be available to low- and middle-income countries at a target price of US$2.00 per dose. Three WHO-prequalified PCV products are now available: PNEUMOSIL, Synflorix® (GSK), and Prevenar-13® (Pfizer).

A global call for action to end preventable child pneumonia deaths

PCV and other vaccines are critical parts of our pneumonia prevention and control toolkit, but the best strategy to effectively combat pneumonia is a comprehensive, evidence-based approach that includes a package of interventions. That means national and global commitments to protecting children—especially the most vulnerable—by promoting exclusive breastfeeding and improving nutrition, preventing HIV, reducing indoor air pollution, improving access to clean water and effective sanitation, ensuring early diagnoses and treatment, and fully immunizing every child.

Infographic by WHO/UNICEF, 2013, Ways to end preventable child pneumonia deaths
WHO/UNICEF, 2013

Ending preventable child pneumonia deaths is a challenge of global proportions that demands dogged determination; practical, evidence-based strategies; and a unified voice committed to meeting the Sustainable Development Goals and Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea targets.

Learn more about pneumonia and the value of immunization in the VoICE Compendium

Follow @Stop_Pneumonia for updates from this week’s Global Forum on Childhood Pneumonia and @voice_evidence to learn more about the broad, lasting benefits of immunization.

Photo credits: Amanda Mustard for Johns Hopkins University and Thomas Rippe

Vaccination: Helping children think, learn and thrive

Infographic describing Immunization, schooling and future prospects
Posted on by stacy

A selection of VoICE evidence in this issue

Berger JT, Villalobos ME, Clark AM et al. 2017. Cognitive development one year after infantile critical pertussis. Pediatric Critical Care Medicine. 19(2).

Lorntz, B., Soares, A.M., Moore, S.R., et al 2006. Early childhood diarrhea predicts impaired school performance. Pediatric Infectious Disease Journal. 25(6).

Krauss-Mars, A.H., and Lachman, P.I. 1992. Social factors associated with tuberculosis meningitis. South African Medical Journal. 81(1).

Niehaus, M.D., Moore, S.R., Patrick, P.D., et al 2002. Early childhood diarrhea is associated with diminished cognitive function 4 to 7 years later in children in a northeast Brazilian shantytown. American Journal of Tropical Medicine and Hygiene. 66(5).

Driessen J, Razzaque A, Walker D, et al. 2015. The effect of childhood measles vaccination on school enrolment in Matlab, Bangladesh. Applied Economics. 47(55).

Mina, M.J., Metcalf, C.J. de Swart, R.L., et al 2015. Long-term measles-induced immunomodulation increases overall childhood infectious disease mortality. Science. 348(6235).

Nandi A, Shet A, Behrman JR, et al. 2019. Anthropometric, cognitive, and schooling benefits of measles vaccination: Longitudinal cohort analysis in Ethiopia, India, and Vietnam. Vaccine. 37.

A healthy child is more likely to attend school, performs better in school and attends school for longer than a child who is often ill or has suffered permanent disabilities as a result of illness. In this Feature, VoICE explores how vaccine-preventable infections affect cognitive development and schooling, and highlights evidence of the effect vaccination can have in protecting a child’s neurologic development, educational prospects and ultimately, future productivity.

Key Messages

  1. Common childhood illnesses cause children to miss school. Immunized children miss less school.
  2. Recurring episodes of diarrhea in young childhood can delay a child from starting school and affect physical growth and normal cognitive development during childhood. Vaccine-preventable rotavirus is the most common cause of severe diarrhea.
  3. Immunization against measles can increase the number of years of schooling a child achieves and may also improve cognitive scores, compared to unimmunized children.
  4. Some vaccine-preventable infections carry the risk of long-term hearing, psychosocial and neurological disabilities that negatively impact a child’s social functioning and educational prospects.
  5. On average, globally, each additional year of schooling can increase a child’s future adult earnings by more than 12%.

Immunization protects our children’s future prospects

Most people think of vaccines as important for preventing specific diseases and infections during childhood, but may not realize the extent to which immunization can strengthen a child’s future prospects well into the school years and beyond. Growing evidence is illuminating the link between vaccination and improved cognitive functions, education, and ultimately, adult productivity. In essence, vaccination may help improve a child’s ability to learn, think and thrive in society as a result of educational attainment, cognitive reasoning and thinking skills.

Immunization, Schooling and future Prospects

Vaccine-preventable diseases, immunization and educational attainment

Vaccinated kids miss less school

The most obvious link between immunization and education is that preventing bouts of illness means kids miss fewer school days. A study of school absenteeism in the US found that nearly 50% of absences were due to illness. A second US study found that schools that offered flu vaccine to their students reduced the risk of any child getting the flu by 30%, regardless of vaccination status. Children vaccinated against the flu missed 1.5 fewer days of school per 100 school days compared to those who did not receive flu vaccine. Thirty years ago, Varicella infections (chickenpox) caused a child to miss nearly 9 days of school, not to mention work missed by parents taking care of a sick child. But the introduction of chickenpox vaccine in 1995 has drastically reduced infections, hospitalizations and deaths from this common infection, preventing more than 3.5 million cases each year in the US, according to the CDC.

Infections and schooling delays

Rotavirus is the most common cause of severe diarrhea in young children worldwide, and researchers in Brazil found that recurrent bouts of diarrhea affect school readiness and long-term educational attainment. In children living in a Brazilian shantytown, the greater the number of episodes of persistent diarrhea before age two, the more delayed a child was in terms of school readiness. Overall, each episode of diarrhea delayed a child’s starting school by 0.7 months. Likewise, 6-10 years later, increasing episodes of diarrhea before age two predicted delays in age-appropriate educational attainment. Some infections, such as tuberculosis meningitis, although rare, significantly increase the risk of major educational delays. From a study in Western Cape, South Africa, among children who were well enough to attend school after surviving tuberculosis meningitis, more than half had failed at least one school grade.

Measles vaccine can help increase extent of education received

Measles infection has a well-known prolonged negative impact on the immune system, increasing the risk of other illnesses for up to 3 years after recovering from measles. A 2019 analysis of survey data from school aged children in Ethiopia, India and Vietnam shows that children vaccinated against measles achieved 0.2-0.3 years of additional schooling compared to children who did not receive the measles vaccine. As depicted in the graphic below, note that this value is as high as 0.8 years of schooling by age 11-12. Similarly, data from a poor, largely rural South African community found that for every 6 children vaccinated against measles, one additional grade of school was achieved. In terms of initial enrollment in school, the phased introduction of measles in Bangladesh in the 1980’s resulted in boys being more than 7% more likely to be enrolled in school if they were vaccinated during the first year of life, compared to unvaccinated boys or those vaccinated later in childhood. This effect was not observed for girls, but may suggest that overall physical and cognitive health of children – as a result of their measles vaccination status – played a role in parent’s decisions to enroll their children in school.

Measles Vaccination Associated with Increased Schooling

Maternal vaccination can help a child’s education

In 1974, a randomized trial of tetanus vaccine was designed to determine how well maternal vaccination would protect infants born to mothers in Bangladesh from tetanus. The study showed a significantly reduced risk of tetanus infection and death among infants born to mothers who had received the vaccine. Notably, 20 years later, researchers found a clear pattern of increased educational attainment among children whose mothers received tetanus vaccine during pregnancy. Helping to explain this observation is the fact that up to 50% of children who survive neonatal tetanus may have long-term cognitive impairment as a result of the infection.

Vaccine-preventable diseases affect the ability to learn, think and function socially

Long-term impairments resulting from vaccine-preventable infections can reduce a child’s educational prospects in several ways. Not only may the impairment itself represent a barrier to learning and future productivity, as in the case of significant cognitive delays, but educational support for children affected by these and other impairments may be lacking or nonexistent. In many places around the world, educational systems and local school are stretched exceedingly thin and unable to provide specialized assistance to children with hearing, vision, developmental or other impairments.

Vaccine preventable infections in childhood can negatively affect a child's education

Hearing impairments

In the era before the introduction of pneumococcal conjugate vaccine (PCV) in the US, pneumococcus was the most common cause of serious and recurring ear infections in children. In comparison to life-threatening meningitis or severe pneumonia brought on by pneumococcal infection, an ear infection may seem trivial. But from the perspective of learning, ear infections can have serious consequences. Multiple ear infections in early childhood increase the risk of hearing loss, and that speech and language develops during the same time in which most children are at the greatest risk of ear infections. These factors help explain why children who spent more time with ear infections during early childhood had lower cognitive, speech, language development and even IQ than children who suffered less time with ear infections, according to a 1990 study in the US. More recently, a 2015 review of long-term impairments resulting from invasive meningococcal disease – which is relatively rare in the era of meningococcal vaccines – was significantly associated with permanent hearing loss in survivors.

Social and psychological impairments

Another set of challenges presented to survivors of vaccine-preventable diseases includes behavioral, social and psychological disorders. The invasive meningococcal disease review above highlighted evidence that children who survived invasive meningococcal infections were nearly 15% more likely to have a significant psychological disorder 3-5 years after the disease than children who did not have the disease, and two studies found a significant association between the disease and later development of Attention Deficit Hyperactivity Disorder (ADHD).

Vaccine-preventable brain and brain-related infections and long-term cognitive impairment

Vaccines can prevent several infectious causes of severe brain and brain-related infections such as meningitis or encephalitis. These types of infections are not only life-threatening but are highly associated with impaired thinking and learning after infection, sometimes for the rest of one’s life. Vaccines that prevent these infections thus help protect and preserve one’s future ability to learn, engage socially and thrive in society.Infection with Japanese encephalitis virus (JEV), which circulates almost exclusively in Asia, usually results in mild or undetectable symptoms. However, in those who develop encephalitis, a serious inflammation of the brain, 1 in 4 do not survive. Among those who do survive, up to 50% are left with permanent cognitive, psychological or neurological disabilities. An effective vaccine is available and the WHO recommends its inclusion in the national immunization schedules of heavily affected countries.Another life-threatening infection of the central nervous system is meningitis, which may have viral or bacterial causes. A large portion of the most severe meningitis infections were caused by three bacteria – pneumococcus, Hib and meningococcus – which are now largely vaccine-preventable. Pneumococcal, Hib and meningococcal infections have been responsible for the majority of meningitis deaths among children and for significant numbers of permanent cognitive disabilities, making their prevention high on the list of priorities for safeguarding a child’s future prospects. In The Gambia, 58% of children who survived pneumococcal meningitis had long lasting negative health outcomes. Half had major disabilities such as mental retardation, hearing loss, motor abnormalities, and seizures. A systematic literature review of studies across Africa found that 25% of children who survived pneumococcal or Hib meningitis had neuropsychological deficits.

The link between diarrhea, physical growth and cognition

Especially during early childhood, good nutrition and physical growth are needed for normal cognitive development. Diarrhea, especially severe or recurring diarrhea, limits the absorption of nutrients in the body, which can affect physical and cognitive development in the long-term. (See the VoICE Featured Issue on Nutrition, Growth and Development). Many rotavirus infections can be prevented through the use of existing vaccines. Prevention of diarrhea is another way to safeguard cognitive development, based on these sobering facts:

Some vaccines have been linked to improved learning and cognitive development

Some evidence in the last 10 years points to a positive link between vaccination in early childhood and a corresponding gain in cognitive and learning tests in later childhood. A small study from the Philippines found that children immunized with 6 basic vaccines scored better on three cognitive tests (verbal, mathematics and language) at age 11 compared to children who received none of these 6 vaccines. A 2019 analysis of survey data from India, Ethiopia and Vietnam found that children vaccinated against measles scored better on cognitive tests of language development, math and reading than children who did not receive measles vaccines.

Vaccination as an investment in future productivity

Reporting on the Philippine study of cognition and vaccination, David Bloom and colleagues at Harvard University note that improvements in a child’s health translate into better earning potential and productivity as an adult, and thus describe vaccination as “an investment in human capital”, highlighting several studies that support this idea. Educational attainment is an important part of the equation for reaping the rewards of such investments. A 2014 World Bank review of the returns to schooling worldwide found a significant positive relationship between additional years of schooling and future adult wage earnings. Not only were the returns from schooling greatest in low- and middle-income countries, but the highest returns to schooling came from the primary years of education – years in which the influence of early childhood illnesses is the strongest. On average across Africa, the report concludes that an additional year of schooling would yield a 12.4% increase in future adult earnings.A healthy child is more likely to attend school, performs better in school and attends school for longer than a child who is often ill or suffering permanent disabilities as a result of illness. The list of consequences from vaccine-preventable illnesses is long and frightening. Each threat erased from that list by vaccination is another hurdle removed from a child’s path to an education and a full and productive adulthood.

Commentary from the VoICE editors

The literature investigating the linkages between immunization, education and cognition represents a complex web of research areas spanning epidemiology, neuroscience, economics, education and demography. Studies specifically and quantitatively looking at the relationships between vaccines and education or cognition are relatively few, and some are older than the literature typically covered in VoICE. Although the positive link between immunization and educational attainment is generally accepted, the lack of new studies on this topic highlights the need for additional focus on this area of study. Although the complexity of these linkages makes quantifying the effect of immunization on education and future productivity difficult, all the literature reviewed in VoICE demonstrates a clear positive – and logical – relationship between immunization and improvements in thinking, social development, schooling and educational success.

Vaccine-preventable Outbreaks: Becoming All Too Common and Costly

Infographic of words related to outbreak
Posted on by stacy

From Abuja to Atlanta, recent infectious disease outbreaks have all too commonly captured the regular news headlines. In this Featured Issue on vaccine-preventable disease outbreaks, the VoICE team goes past the headline, down to the fine print. We bring you an evidence-backed overview of vaccine-preventable infectious disease outbreaks worldwide, with a special focus on the circumstances that increase the likelihood of an outbreak, the less-obvious health and economic consequences, and a “top five” list for outbreak prevention and preparedness.

A selection of VoICE evidence in this issue

Paniz-Mondolfi AE, Tami A, Grillet ME et al. 2019. Resurgence of vaccine-preventable diseases in Venezuela as a regional public health threat in the Americas. Emerging Infectious Diseases. 25(4).

Suijkerbuijk AWM, Wondenberg T, Hahne SJM et al. 2015. Economic costs of measles outbreak in the Netherlands, 2013-2014. Emerging Infectious Diseases. 21(11).

Culver A, Rochat R, Cookson S 2017. Public health implications of complex emergencies and natural disasters. Conflict and health. 11(1).

Hammer CC, Brainard J, Hunter PR 2018. Risk factors and risk factor cascades for communicable disease outbreaks in complex humanitarian emergencies: a qualitative systematic review. BMJ Global Health. 3.

Calugar A, Ortega-Sanchez I, Tiwari T et al. 2006. Nosocomial pertussis: Costs of an outbreak and benefits of vaccinating health care workers. CID. 42.

Coltart CE, Johnson AM, Whitty CJ 2015. Role of healthcare workers in early epidemic spread of Ebola: policy implications of prophylactic compared to reactive vaccination policy in outbreak prevention and control. BMC Medicine. 13(271).

Huber C, Finelli L, Stevens W 2018. The economic and social burden of the 2014 Ebola outbreak in West Africa. JID. 22(5).

Takahashi S, Metcalf JE, Ferrari MJ et al. 2015. Reduced vaccination and the risk of measles and other childhood infections post-Ebola. Science. 347(6227).

Dayan GH, Ortega-Sanchez IR, LeBaron CW et al. 2005. The cost of containing one case of measles: the economic impact on the public health infrastructure — Iowa, 2004. Pediatrics. 116(1).

Constenla D., Carvalho A., Guzman NA. 2015. Economic impact of meningococcal outbreaks in Brazil and Colombia. Open Forum Infectious Diseases. 2(4).

Colombini A, Badolo O, Gessner BD et al. 2011. Cost and impact of meningitis epidemics for the public health system in Burkina Faso. Vaccine. 29.

Pike J, Tippins A, Nyaku M et al. 2017. Cost of a measles outbreak in a remote island economy: 2014 Federated States of Micronesia measles outbreak. Vaccine. 35(43).

Bambery Z, Cassell CH, Bennell RE et al. 2018. Impact of hypothetical infectious disease outbreak in US exports and export-based jobs. Health Security. 16.

Hagan JE, Greiner A, Luvsanshavar UO et al. 2017. Use of diagonal approach of health system strengthening and measles elimination after a large nationwide outbreak in Mongolia. Emerging Infectious Diseases. 23.

World Health Organization 2017. Weekly epidemiological record, Cholera vaccines: WHO position paper – August 2017. WHO Weekly epidemiological record. 92(34).

Jonas, O., Katz, R., Yansen, S., et al. 2018. Call for independent monitoring of disease outbreak preparedness. BMJ. 361.

Key Messages

  1. Infectious disease outbreaks can happen anywhere and have significant, and often hidden, social, health and economic repercussions.
  2. A large proportion of recent infectious disease outbreaks are of vaccine-preventable diseases.
  3. The likelihood or severity of an outbreak is increased by factors such as low vaccination coverage, crowding, poor sanitation, malnutrition, and human mobility.
  4. Outbreak prevention and preparedness needs to be systematically integrated into health systems and specific areas must urgently be strengthened to include immunized healthcare workers, streamlined health communications, and ready surveillance systems.

Introduction

Disease outbreaks happen in nearly every corner of the globe – from the remote Amazon to Amsterdam. An analysis of a World Health Organization (WHO) epidemics database found that from 2005-2014, nearly 400 outbreaks of infectious disease (not including measles) were reported to the WHO. Nearly 40% of these outbreaks were due to vaccine-preventable diseases (VPDs) – with yellow fever, polio, meningococcal disease and cholera accounting for 9/10  of the outbreaks due to VPDs.  The proportion of outbreaks caused by VPDs was as high as 70% in the African region. The ubiquity of disease outbreaks globally speaks to the range of complex factors that contribute to outbreaks of various infectious diseases, but there are some combinations of factors that can easily ignite an outbreak of epidemic proportions.

Outbreak, epidemic, or pandemic?

Outbreak Highlight Box-Outbreak Epidemic Pandemic

A Fire Waiting to Happen:

Circumstances that increase the risk of outbreaks

There are a triad of elements that influence the likelihood and severity of an infectious disease outbreak. These include factors related to:

  1. The Pathogen – aspects of the disease agent itself (virus or bacteria), such as how it is transmitted from person to person, how contagious it is, the incubation period before symptoms appear, how severe the infection may be and how likely it is to result in death.
  2. The Population – factors affecting the state of health of the population at risk, including the proportion vaccinated, malnourished or living in sub-optimal conditions such as overcrowding, and how people move on small or large spatial scales.
  3. The Environment – generally refers to environmental factors that affect the spread of disease such as access to clean water and sanitation, access to health care, social norms and cultural practices – for example in the case of Ebola where traditional burial practices bring people into contact with infected bodily fluids which transmit the virus.

Figure 1: Pathogen, population, and environmental factors can ignite an outbreak of infectious disease.

Outbreaks

An outbreak can ignite when sparked by only a handful of the factors described above, such as in the case of measles or pertussis – two highly contagious pathogens which can rapidly take advantage of gaps in vaccine coverage. In other circumstances, parts of all three elements – pathogen, population and environment – are present and create the perfect conditions to kindle an outbreak.

Cracks in the immunization firewall

A high firewall of immunization coverage with very very few gaps is required to protect populations from outbreaks of highly transmissible and contagious infections, such as measles or pertussis, which have the potential to spread rapidly and far. An infection like measles is so contagious that almost all susceptible people who are exposed will become infected meaning that about 95% of a community needs to be protected to stop measles virus transmission. Add to that the fact that contagiousness occurs before the telltale rash (and very often before anyone knows what is causing the illness), and you can see how just those two pathogen-related factors cause some outbreaks to explode. In a community with lower than 95% vaccine coverage, the exposure of a single person without immunity to the virus is the single spark that is needed to start an outbreak that quickly burns through a community of people who have little or no immunity. The connection between measles and low vaccination coverage is so strong that some researchers describe measles outbreaks as being a “canary in a coalmine” that brings to light programmatic weaknesses in immunization coverage in places where data on vaccination coverage is thin or unreliable.

Figure 2: Factors contributing to measles outbreaks.

The firewall for a disease like Ebola must be just as strong but for different reasons. Ebola is not very contagious when compared to other infections, but has an exceedingly high risk of death – up to 70% with some strains. (An animated visualization from the Washington Post of the relative contagiousness and mortality risk of different diseases.) When and exactly where the disease will appear is impossible to predict (see “The case of Ebola, a zoonotic infection”, below) and a vaccine against the disease has not yet been approved. For these reasons, outbreak control measures for Ebola, including significant efforts to find people who have been exposed, must be swift and widespread. An experimental vaccine for Ebola is being used in a “ring” vaccination strategy to vaccinate everyone who has come in contact with someone who has the disease, and has proven to be nearly 100% effective in preventing infection, if administered soon enough after exposure. Gaps in this vaccination ring mean the deadly disease has the potential to continue spreading.

Complex emergencies

Global socio-political events, including armed conflicts and other complex humanitarian emergencies, can result in a highly flammable set of circumstances – a “box of matches” containing nearly every population and environmental factor, which can easily spark a significant outbreak. In a study of the overlap between complex humanitarian emergencies and disease outbreaks, researchers found that more than 40% of complex emergencies that occurred between 2005-2014 were associated with an outbreak of infectious disease, with a high likelihood that the outbreak was vaccine-preventable.

The mass migration of people that often results from complex humanitarian emergencies can set off a “risk factor cascade”, that includes decreasing vaccination coverage, undernourishment, overcrowding, and poor sanitation, dramatically increasing the risk of an outbreak with each added cascade factor.

When environmental conditions are poor and pathogen-related factors are significant, only a tiny spark is required to ignite an outbreak, as is often the case with cholera. The bacteria that causes cholera (Vibrio cholera), a highly contagious diarrheal disease, can be quickly passed to large numbers of people through contaminated water in crowded and poorly-resourced settings such as urban slums or refugee camps that have poor access to clean water and sanitation. Rainfall further spreads the contaminated water, sustaining the outbreak. Population factors, such as undernutrition further worsen the disease.  Undernourished people are at greater risk of severe cholera infections and of dying from the infection.

Figure 3: Factors contributing to cholera outbreaks.

Outbreaks, Figure 3, Cholera

The case of Ebola, a zoonotic infection

Most vaccine-preventable outbreaks are due to pathogens which circulate constantly among humans, causing spikes in disease when population and environmental conditions allow. Ebola, however, is a zoonotic infection, meaning that the normal reservoir for the pathogen is among animals, most likely bats. Ebola outbreaks among humans are triggered when people come into contact with infected animals (such as through the consumption of bush meat from infected primates), become ill and then pass the virus to other humans where it spreads until it can be contained.

Predicting when and where the virus will strike and spark an outbreak is thus very difficult, which significantly adds to the challenges of planning for, controlling and mitigating the impact of outbreaks. Ebola is one of several diseases of zoonotic origins  that has the potential to ignite a global pandemic, according to USAID.

The Repercussions of Vaccine-Preventable Outbreaks

While outbreaks of measles and Ebola have been widely covered in the news media, a less visible topic has been the significant – and sometimes long-term – health and economic repercussions that come along with outbreaks of these and other diseases.

Repercussions on health systems

By definition, an outbreak is the occurrence of disease in a population that rises above expected levels. Although contingency plans may be in place for dealing with an outbreak, health staff, funding, medical supplies and other resources are often diverted to outbreak control, weakening the provision of other health services. In one example from Burkina Faso in 2007, meningitis epidemics disrupted health services at every level. Impact on all people seeking healthcare included longer wait times to be seen, increased time for lab test results, higher stress among caregivers and an increase in the number of misdiagnoses by overtaxed health care workers (HCWs).

Repercussions for healthcare workers

The burden on HCWs, in fact, extends beyond exhaustion and the mental toll of working in outbreak conditions. Health workers themselves are at significant risk of becoming victims of an infectious disease outbreak and passing on the infection to others, in particular before the infectious agent has been identified. HCWs can account for a substantial proportion of disease cases. A recent study using data from historical outbreaks of Ebola in Guinea and Nigeria, found that (had a fully effective vaccine been available at the time of those outbreaks) prophylactically vaccinating healthcare workers would have decreased the size of the Ebola epidemics in those countries by 60-80%. In the US, researchers estimated that ensuring full vaccination of healthcare workers would prevent more than 45% of exposures to pertussis that occur in healthcare settings. These are only two of many examples illustrating the disproportionate burden of disease cases among HCWs, all of which highlight critical gaps in vaccine coverage among people at significantly increased personal risk, and risk of infecting others. (For more on the WHO’s recommendations for immunizing health care workers.)

Repercussions of every kind: The Ebola firestorm

Outbreaks of exceptionally deadly infectious diseases such as Ebola can cause a cascade of events affecting every person and sector in a community and thus represent a firestorm of all the potential repercussions of an outbreak occurring at once. Huber et al described the devastating and far-reaching impact of the 2014 Ebola outbreak in West Africa, including more than half a million people experiencing food insecurity, school closures lasting more than 7 months, tens of thousands of children orphaned, a huge proportion of the health workforce killed by the disease, infant, maternal and child deaths from lack of skilled health workforce and a 97% reduction in surgical capacity, to name a few. A second study projected that the crippling of immunization programs resulting from the Ebola outbreak could double the number of people at risk for measles, ultimately killing nearly as many people as Ebola itself.

Ebola Treatment Center in Beni, Democratic Republic of the Congo’s North Kivu Province
At ALIMA’s (The Alliance for International Medical Action) Ebola Treatment Center in Beni, Democratic Republic of the Congo’s North Kivu Province, health workers care for patients infected with Ebola within ALIMA’s innovative biosecure emergency care unit – the CUBE.

Economic repercussions: costs of outbreaks

Adding to the secondary health and societal costs of infectious disease outbreaks are the actual monetary and economic impacts, which are significant even in a relatively small and quickly contained outbreak. The larger and longer an outbreak, the more significant its macroeconomic impacts on productivity, import & export losses, reduced tourism revenue and consumption.

From cholera to measles to Ebola, health economists have published several studies on the economic impact of outbreaks, covering direct costs of outbreak management to slowed national economic growth as a result of outbreaks. Direct costs to health systems include outbreak investigation costs such as personnel, supplies, travel expenses to find people exposed to infection and outbreak containment efforts including vaccination or prophylactic treatment costs for those exposed. Costs to individual families seeking treatment can be significant and have long-term economic consequences. Productivity losses and reduced consumption and revenue directly affect nations dealing with outbreaks, but shifts in imports and exports internationally can impact other nations economically, despite not being directly affected by the outbreak. Just some of the economic repercussions can be found in the cases below:

Outbreak Prevention and Preparedness

The prevention, mitigation and control of infectious disease outbreaks is becoming more urgent, while the number of emerging diseases increases, populations are more mobile and economies are stretched thin. Addressing infectious disease outbreaks must be a high political priority, requiring investments of both financial support and political will. But investments in what exactly?

It will come as no surprise that vaccination features prominently in our “TOP FIVE” list of investments that must be made to better prevent and prepare for outbreaks of infectious disease. What may be surprising is that financing, purchasing and delivering vaccines to the general population is only one of the necessary steps towards ensuring that the full potential of immunization can be realized in helping to prevent, mitigate and control outbreaks. Clear and actionable preparedness plans, robust health systems with increased access to health care, and significantly increased investments in disease surveillance and health communication round out our list.

Top Five Investments In Outbreak Prevention And Preparedness

1. Investment in health systems, including routine immunization

A country’s ability to prevent, detect and respond to outbreaks is tied to the strength and capacities of its health system overall. As such, a 2018 multi-stakeholder outbreak preparedness framework includes strengthening overall public health system capacity as the first of four pillars in the prevention of significant disease epidemics and pandemics.

National and subnational health systems supported by recommended levels of funding, high political priority and strategic planning processes that include the integration of emergency preparedness and everyday health systems operations are more resilient to emergencies such as disease outbreaks, and can recover more quickly. A 2016 WHO-led consultation with countries in the African region found that health systems and health security-related structures functioned independently from one another, but that strong support existed for the integration of emergency prevention and preparedness in broader health systems.

Given the high proportion of outbreaks due to vaccine-preventable infectious diseases, immunization has an especially important role to play in the prevention of disease outbreaks, and is thus critical for emergency prevention and preparedness.

2. Full immunization for health workers

High coverage of routine immunization is a critical firewall to prevent outbreaks from occurring, and vaccination of healthcare workers is especially critical to minimizing the spread of an emerging outbreak. Several studies have demonstrated the significant return on investment to be had by ensuring HCWs are fully immunized, given that HCWs often account for a disproportionately large number of disease cases. In the US study looking at prevention of the spread of pertussis referenced above, the financial return on vaccinating healthcare workers in hospitals was estimated to be nearly two and a half times the cost invested. A similar study of pertussis vaccine and HCWs in the Netherlands estimated the return on investment to be four times as great as the initial cost.

3. Actionable preparedness plan

Despite strong evidence that prevention and preparedness provide a sizeable return on investment, compared to the costs of an unchecked outbreak of disease, between 2016 and 2018 only one third of countries had assessed their own capacity to prevent, detect and control disease outbreaks.[1] That number has now risen to just under half, but nearly 80% of countries who have completed a preparedness assessment are wholly or partially unprepared for an outbreak of disease.[1] Experts argue that the cycle of panic and neglect in addressing disease outbreak readiness is a crisis of global proportions, and one which can only be broken by implementing and monitoring concrete preparedness plans.

4. Public health communications

Following recent global disease events like Ebola and SARS, which ignited global panic about the outbreaks and their impact, recognition has been increasing of the importance of consistent, clear and culturally sensitive communication with the public around health issues. Investment of money and time in this area, however, still lags behind the need. The WHO’s Outbreak Communication guidelines emphasize not only what needs to be done to communicate during an outbreak, but also the importance of building and maintaining trust in national and health authorities among all communities as a foundation for health communications and care seeking overall. Trust in an existing foundation of open, clear communication can help immunize against panic and increase compliance with measures intended to control and end outbreaks.

5. Infectious disease surveillance

The importance of disease surveillance, robust enough to detect outbreaks early, cannot be overstated, and yet, it is an area that is often poorly integrated in the broader public health system, and is chronically underfunded. Considered an essential public health capacity, investments in surveillance as it relates to outbreak detection and control are likely to have important benefits for other health priorities and diseases. For example, polio detection systems in the Americas were leveraged to better detect measles and rubella. Likewise, laboratory experience with measles and rubella surveillance led to the early detection and response to the H1N1 influenza virus in Mexico in 2009.

In summary, the specifics of the strategy for implementing each of these actions vary based on the type of outbreak. For example, the current vaccination strategy for Ebola includes finding and vaccinating all people who have come in contact with someone who has the disease (and all of those contacts’ contacts) to form a “ring” of immunity around disease cases. By contrast, measles and pertussis vaccines are recommended for all children worldwide during early childhood. Despite such differences in the specific approach needed, each of these five areas above are critical for mitigating the immediate impact and secondary repercussions of all future outbreaks.

[1] Jonas, Katz, et al. Call for independent monitoring of disease outbreak preparedness. BMJ. 2018;361:k2269 doi: 10.1136/bmj.k2269

Editorial Commentary

“We are witnessing an apparent increase in the magnitude and frequency of outbreaks due to vaccine-preventable diseases, as adroitly described in this VoICE Featured Issue. Such outbreaks are, by definition, preventable and thus a tragedy, resulting in pointless deaths, countless disabilities, loss of productivity, and economic costs. We must do better. We call on policy makers, community leaders, and the global public health community to improve surveillance systems to detect outbreaks as early as possible, improve vaccination coverage to ensure all children are appropriately immunized, and effectively communicate the benefits of vaccination so trust in public health is restored. We will face new infectious disease threats. We must control those diseases for which we already have safe and effective vaccines so we are best prepared to deal with the emerging ones.”

William Moss, MD, MPH
Interim Executive Director, International Vaccine Access Center

William Moss, MD, MPH is Interim Executive Director, at the Johns Hopkins Bloomberg School of Public Health’s, International Vaccine Access Center (IVAC), a pediatrician and infectious disease specialist who has dedicated the last three decades to improving the lives of children through better treatment and prevention of infectious disease. Dr. Moss has made significant contributions in many areas, including HIV, malaria, complex humanitarian emergencies and especially measles, for which he is a member of the World Health Organization’s expert Working Group on Measles and Rubella.

World Immunization Week 2019

Infographic showing 4 different cartoon families under 1 umbrella, text that says "Children with cancer, and other people with weakened immune systems, rely on vaccination and herd immunity to protect them from infection.""
Posted on by stacy

Social Media Toolkit

Using evidence for advocacy: Visit the 2019 World Immunization Week social media toolkit! Explore our messages, graphics, and gifs illustrating how #VaccinesWork to keep us #ProtectedTogether. Topics include:

  • #ProtectedTogether: Herd immunity
  • #ProtectedTogether: Mothers and babies
  • #ProtectedTogether: Family-level economic protection
  • #ProtectedTogether: Country-level economic protection
  • #ProtectedTogether: Strengthening health systems

Download the IVAC VoICE WIW Social Media toolkit, with instructions to download animations.

Access all of the materials in this folder.

#ProtectedTogether: Herd immunity

Tweet 1a

Even unvaccinated kids are protected against rotavirus when coverage is high. @VoICE_Evidence #ProtectedTogether #VaccinesWork http://bit.ly/2YZs5Lv

Tweet 1b

Children with cancer and those with weakened immune systems rely on vaccination and herd immunity for protection from vaccine-preventable diseases. Vaccines help ensure these kids are #ProtectedTogether! @VoICE_Evidence #VaccinesWork http://bit.ly/2Kqphnp

Tweet 1c

3 for 1 deal on preventing pneumococcal infections! #VaccinesWork #ProtectedTogether @VoICE_Evidence http://bit.ly/2G34qBq

#ProtectedTogether: Mothers and babies

Tweet 2a

Moms get vaccinated to protect themselves AND their children – before and after they are born #ProtectedTogether #VaccinesWork @VoICE_Evidence http://bit.ly/2G2uxbF

#protectedTogether Gif

Tweet 2b

Children of empowered Nigerian mothers more than twice as likely to be vaccinated. Empowerment means mothers and children are #ProtectedTogether. #VaccinesWork @VoICE_evidence  http://bit.ly/2P1FluL

Mothers holding their children

Tweet 2c

Empowering women can lead to greater vaccination rates among children. #ProtectedTogether #VaccinesWork @VoICE_Evidence http://bit.ly/2UuQ6vg

Mothers holding their children

#ProtectedTogether: Family-level economic protection

Tweet 3a

4.5 million cases of poverty prevented with… measles vaccine! Health and wealth #ProtectedTogether #VaccinesWork @VoICE_Evidence http://bit.ly/2UKpRAj

Measles vaccination protects health and wealth

Tweet 3b

Costs to treat diarrhea push 160,000 Ethiopian families into poverty. Rotavirus vaccines, help health & wealth stay #ProtectedTogether. @VoICE_Evidence #VaccinesWork http://bit.ly/2KprjUM

vaccines helps health and wealth

Tweet 3c

Costs to treat pneumonia pushed 59,000 Ethiopian families into poverty in 2013. But now PCV and Hib vaccines help the health & wealth of Ethiopian families stay #ProtectedTogether. @VoICE_Evidence #VaccinesWork http://bit.ly/2KprjUM

Tweet 3d

#VoICE_Evidence: Costs to treat their child’s rotavirus infection were “catastrophic” for 1 in 3 Malaysian families. Vaccines ensure families’ health and wealth are #ProtectedTogether #VaccinesWork http://bit.ly/2GdFisG

#ProtectedTogether: Country-level economic protection

Tweet 4a

PREVENTED: 24 million cases of poverty due to medical expenses over 15 years in 41 countries. #VaccinesWork #ProtectedTogether  @Gavi @VoICE_Evidence http://bit.ly/2UFZQCo

Infographic

Tweet 4b

Spend $1 on vaccines for the developing world and get a 16X return! Health & Wealth #ProtectedTogether thanks to #VaccinesWork. #VaccinesWork @VoICE_Evidence @Gavi http://bit.ly/2G6oJO2

infographic

Tweet 4c

$544Billion in productivity losses and medical treatment costs averted in 73 Gavi countries thanks to vaccines. Health and wealth #ProtectedTogether! #VaccinesWork @VoICE_Evidence  http://bit.ly/2P22Xz2

#ProtectedTogether: Strengthening health systems

Tweet 5a

Vaccines keep health systems healthy by preventing costly infections. #ProtectedTogether #VaccinesWork @VoICE_Evidence http://bit.ly/2P22Xz2

Tweet 5b

#ProtectedTogether: In Kenya, rates of pneumonia hospitalizations in children <5 dropped by 27% after 4 years of PCV10. #VaccinesWork to reduce hospital admissions and free up more resources to treat and prevent other illnesses @VoICE_evidence https://bit.ly/2Im0xfk

VIDEO INSERT HERE: https://www.dropbox.com/s/7z94hnzefdto2qk/Tweet%205b_PCV%20Hospitalizations.mp4?dl=0

Tweet 5c

Bangladesh: no hospital bed available for 1 in 4 sick kids. Vaccines keep kids out of hospitals. Healthy kids, healthy health systems #ProtectedTogether #VaccinesWork @VoICE_Evidence http://bit.ly/2Uvqf6w

Tweet 5d

Keeping kids healthy with rotavirus vaccines eases the burden on hospitals and frees up resources for other patients. Health systems and children stay #ProtectedTogether #VaccinesWork @VoICE_Evidence http://bit.ly/2X09v4b

VIDEO INSERT HERE: https://www.dropbox.com/s/a5w0kxk034nkuog/Tweet%205d_Rota%20Hospitalizations.mp4?dl=0

Critical but complex: Vaccination during conflict and forced migration

Camp de réfugiés en situation d'urgence humanitaire à Cox's Bazar, représentant des tentes, des maisons de fortune et des réfugiés
Posted on by stacy

Conflict and forced migration – resulting in disruption of communities and health systems – amplify the risk factors for infectious disease and increase the urgency of preventive measures such as immunization. While disease outbreaks of measles, cholera, meningitis and even polio in refugee camps may be the most widely covered issues related to immunization in conflict-affected areas and populations, this VoICE Featured Issue explores some of the less-visible, but equally critical aspects. Immunizations play an important role in these settings, considering the threat of malnutrition and antimicrobial resistance, economic pressures, and the urgent need for responsive policies.

A selection of VoICE evidence in this issue

Close, R.M., Pearson, C., Cohn J. 2016. Vaccine-preventable disease and the under-utilization of immunizations in complex humanitarian emergencies.. Vaccine. 34(39).

Teleb N. and Hajjej R. 2017. Vaccine preventable diseases and immunization during humanitarian emergencies: challenges and lessons learned from the Eastern Mediterranean Region. East Mediterr Health J.. 22(11).

Gargano L.M., Hajjeh R., and Cookson S.T. 2017. Pneumonia prevention: Cost-effectiveness analyses of two vaccines among refugee children aged under two years, Haemophilus influenzae type b-containing and pneumococcal conjugate vaccines, during a humanitarian emergency, Yida camp, South Sudan. Vaccine. 35(3).

Von Gottberg, A., de Gouveia, L., Tempia, S., et al. 2014. Effects of pneumococcal vaccine in invasive pneumococcal disease in South Africa. New England Journal of Medicine. 371(20).

Dagan, R., Sikuler-Cohen, M., Zamir, O., et al 2001. Effect of a conjugate pneumococcal vaccine on the occurrence of respiratory infections and antibiotic use in day-care center attendees. Pediatric Infectious Disease Journal. 20(10).

Fireman, B., Black, S.B., Shinefield, H.R., et al. 2003. Impact of pneumococcal conjugate vaccine on otitis media. Pediatric Infectious Disease Journal. 22(1).

Centers for Disease Control and Prevention 2013. Antibiotic resistance threats in the United States, 2013 (Report).

Gargano L.M., Hajjeh R., and Cookson S.T. 2015. Pneumonia prevention during a humanitarian emergency: Cost-effectiveness of Haemophilus Influenzae Type B conjugate vaccine and pneumococcal conjugate vaccine in Somalia. Prehospital and Disaster Medicine. 30(4).

Kadir, A., Shenoda, S., Goldhagen, J., et al. 2018. The Effects of Armed Conflict on Children. Pediatrics. 142(6).

Nellums, L.B., Thomson, H., Castro-Sanchez, E. et al. 2018. Antimicrobial resistance among migrants in Europe: systematic review and meta-analysis.. Lancet Infectious Disease. 18(7).

Gargano, L. M., Tate, J. E., Parashar, U. D., et al. 2015. Comparison of impact and cost-effectiveness of rotavirus supplementary and routine immunization in a complex humanitarian emergency, Somali case study.. Conflict and health. 9(5).

Key Points:

  1. Malnutrition and infectious disease – together set off a dangerous and potentially life-threatening cycle – represent the greatest twin threat to health during humanitarian emergencies. Vaccines can help interrupt the cycle and mitigate some of the risk to refugees and conflict-affected populations.
  2. The spread of antimicrobial resistant organisms and infections may be increased in the conditions present in areas experiencing conflict and significant population displacement.
  3. The provision of immunizations to refugees can be cost-effective and may avert significant treatment-related expenses from infections down the road.
  4. Preparing for emergencies, especially at the policy level, is a critical success factor for countries affected by humanitarian crises and those hosting displaced populations.
CalloutBox

Exhausted, hungry, not sure where they will sleep or bathe, or for how long they may have to stay in a makeshift camp…displaced people arriving in refugee camps are often stepping into a perfect storm of risk factors for poor health and vaccine-preventable infections. Exhaustion, malnutrition and poor access to clean water and sanitation all contribute to increasing a person’s risk of infectious disease. Having taken only what they could carry, these people are also living in poverty (some are newly poor, having abandoned possessions and property to flee the fighting), which is a well-known risk factor for developing vaccine-preventable diseases and further impoverishment. A scene like this only hints at the long list of health risks and challenges facing refugees fleeing from, and families living in, conflict-ridden zones.

Figure 1: The domino effect of humanitarian emergencies and infectious disease

Conflict and forced migration – resulting in disruption of communities and health systems – amplify the risk factors for infectious disease and increase the urgency of preventive measures such as immunization. While disease outbreaks of measles, cholera, meningitis and even polio in refugee camps may be the most widely covered issue related to immunization in conflict-affected areas and populations, in this VoICE Featured Issue we will explore some of the less visible, but equally critical aspects of immunization in these settings including malnutrition, antimicrobial resistance, economics and policy.

Malnutrition and infectious disease

Figure 1 illustrates the domino effect of conflict and other complex humanitarian emergencies on health, in particular nutrition and risk of infectious disease. Ultimately, malnutrition and infectious diseases are significantly worsened in such situations and are responsible for a majority of deaths, even far outstripping trauma and violent injuries due to fighting in areas of active combat, according to a 2011 Technical Report from the World Bank. In a recent Technical Report in the journal Pediatrics, researchers noted that children under 5 years of age bear the greatest burden of indirect conflict-associated mortality, largely due to disruptions in health services, such as vaccination, and access to food.

Several studies have concluded that respiratory and gastrointestinal infections are the two leading causes of death during complex humanitarian emergencies (CHEs) “…independent of geography, time and crisis-type…”, according to a recent review. The authors of this review go on to say, given the close cyclical relationship between infectious diseases and malnutrition, immunization could help defend people against the infectious disease risks that come with malnutrition, a problem which is exceedingly common in humanitarian crises. Pneumococcal, Hib, measles, rotavirus and cholera vaccines can help protect populations who are especially vulnerable to malnutrition .

For more on the nutrition and disease cycle, see our VoICE Featured Issue on the links between malnutrition and infectious disease.

Antimicrobial resistance in refugee settings

Antimicrobial resistance – or the ability of some bacteria to survive treatment with antibiotics – is another heavy burden that rests on those living in and fleeing from conflict zones. A 2018 systematic review found that a quarter of migrants who fled to the European region either carried or were infected with antimicrobial resistant organisms, and that this rate rose to a third of all refugees or asylum seekers.[1] Contributing factors include crowded living conditions with variable access to sanitation, poor overall health, lack of access to vaccines, as well as the exposure to new pathogens stemming from the mingling of large numbers of people originating from geographically distinct areas.

Availability of treatment and other health services in areas of conflict or in newly established refugee camps may be very low, and treatment for antibiotic resistant infections can be particularly difficult and costly, even in well-resourced health systems.

A large review of the use of vaccines in complex humanitarian emergencies stated that the reduction of antimicrobial resistance was an important indirect effect of the use of vaccines in such settings. Immunization helps curb the spread of antimicrobial resistant organisms by preventing infections that might otherwise be treated with antibiotics, thereby decreasing opportunities for the development of resistance. Not only do vaccines decrease the use of antibiotics, but they prevent occurrence of resistant infections. Use of the pneumococcal conjugate vaccine in South Africa has led to significant declines in invasive pneumococcal disease cases caused by bacteria that are resistant to one or more antibiotics. In fact, the rate of infections resistant to two different antibiotics declined nearly twice as much as infections that could be treated with antibiotics.

The economics of immunization and conflict

The conditions present in refugee settings are both logistically challenging – with potentially large numbers of people moving in and out, lack of health records, sanitation, supplies, etc. – and ripe for infectious diseases and outbreaks. These factors make it very difficult to provide enough emergency health and treatment services during emergencies, and such services take time and significant expense to establish. Although delivering vaccines in these settings is not without difficulty, the ability of immunization to prevent illness and disease spread, and to protect malnourished populations carries economic benefits.

Evidence from recent humanitarian crises in Somalia and South Sudan has shown vaccination against Hib and pneumococcal pneumonia would be cost-effective and could reduce pneumonia cases and deaths by nearly 20%. Similarly, researchers conclude that the use of the rotavirus vaccine to reduce diarrheal disease and deaths in Somalia, during its ongoing civil conflict would be cost-effective, even in the face of vaccine delivery challenges.

Where do we go from here?

The number of armed conflicts and forced displacements worldwide is at an all-time high. The majority of people displaced by conflict and other humanitarian emergencies are either internally displaced (within the borders of their country of origin) or flee to neighboring countries. This has led to the greatest burden of care for refugees being placed on developing countries who may themselves be struggling – both economically and programmatically, in terms of the delivery of health services such as immunization.

In the map in Figure 2 below you can see countries with active armed conflict in 2015, marked with a black star, overlaid on a map of the coverage of one dose of measles-containing vaccine – for which the WHO says 90% coverage is needed to avert disease outbreaks – during the preceding year (2014). Although it is not surprising that countries afflicted by conflict are also struggling to achieve high vaccine coverage, it is a reminder that political and health system fragility go hand-in-hand and that these fragile countries are also those most often called upon to help neighbors in crisis.

Figure 2: Armed conflict and low vaccine coverage often occur in the same places.

Coverage of one dose of measles-containing vaccine in countries affected by armed conflict.
Measles coverage map: World Health Organization. WHO/UNICEF coverage estimates. Available at http://www.who.int/immunization/monitoring_surveillance/en 
Armed conflict overlay: Adapted from: Kadir A, Shenoda S, Goldhagen J, et al. The Effects of Armed Conflict on Children. Pediatrics. 2018;142(6)

There have been some notable success stories, for example in Yemen and the Syrian Arab Republic, where vaccination coverage has largely been sustained and is credited with averting a potentially significant burden of preventable infection. Credit for this success is due to the establishment of emergency preparedness procedures and policies in advance of crises and through coordinated programmatic and financial support from governments and partners such as the World Health Organization, UNICEF and non-governmental organizations. Thanks to the readiness of such partners, in October 2018, WHO and UNICEF succeeded in vaccinating more than 300,000 people in Yemen against cholera during a 4-day ceasefire.

The establishment of national policies addressing the health of refugees and migrants is essential step, and challenges abound in both developing and developed nations. In Bangladesh, an engaged health sector, quick government response and an existing multi-sector action plan for disease outbreaks in Bangladesh have been responsible for a robust and ongoing response to vaccine-preventable infections and very low vaccination coverage among Rohingya refugees arriving from Myanmar. In the European region, where more than 30% of the global migrant population resides, only one-third of countries had established policies for the immunization of migrants and refugees. In countries without such policies, many migrants and refugees miss out on vaccinations – either because it is unclear to providers who can be vaccinated and who pays, or because families are not made aware of the mechanisms or opportunities around vaccination.

Humanitarian crises and population displacement are not going away. Limiting the damage to the health of people in crisis will require the swift and broad use of health interventions such as vaccination, policies that help plan for the worst and engaged partners. Best stated by Peter Salama, head of the WHO’s Emergency Response division, “What we really need is international solidarity.”

[1] It is important to note that the greatest risk of AMR related to population displacement is to the displaced themselves. A report released by the World Health Organization last month on the health of refugees and migrants in the European region[1] notes that transmission of antimicrobial resistant infections almost exclusively affects those residing in refugee transit centers and settlements and does not pose an immediate threat to host populations.

For Additional Information:

 To learn more about the relationship between immunization and conflict, migration and complex humanitarian emergencies, see related messages and evidence in the VoICE tool found here: https://immunizationevidence.org/search-immunization-evidence/?fwp_topic=conflict-and-humanitarian-emergencies

World Health Organization, Report on the health of refugees and migrants in the WHO European Region. No PUBLIC HEALTH without REFUGEE and MIGRANT HEALTH; 2018; Geneva, Switzerland.  Found here: http://www.euro.who.int/en/publications/abstracts/report-on-the-health-of-refugees-and-migrants-in-the-who-european-region-no-public-health-without-refugee-and-migrant-health-2018

World Bank. World Development Report 2011 Background Paper, Demographic and Health Consequences of Civil Conflict. 2011. Found here: https://openknowledge.worldbank.org/bitstream/handle/10986/9083/WDR2011_0011.pdf?sequence=1&isAllowed=y

>