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Doing the Almost Impossible Job of Fully Immunizing Every Child

  • Lance E. Rodewald
    Correspondence
    Address correspondence to Lance E. Rodewald, MD, National Immunization Program, Chinese Center for Disease Control and Prevention, 155 Changbai Rd, Beijing 102206, China
    Affiliations
    National Immunization Program, Chinese Center for Disease Control and Prevention, Beijing, China
    Search for articles by this author
      Imagine the enormous effort required to fully immunize every child in the global birth cohort of 140 million – literally, billions of vaccination visits between families and health professionals every year. Despite advances in vaccinology, immunization is still complex, requiring knowledge about schedules, vaccines, indications, contraindications, injection and administration technique, adverse events following vaccination, and vaccine preventable diseases. Parents have to miss work several times a year to bring their child in to be vaccinated. Families are asked to trust the vaccinators, the vaccines, and the vaccination recommendations and have confidence that vaccination is in the best interest of their children.
      The almost impossible job of fully immunizing every child belongs to the world's immunization programs and their networks of providers, which collectively have done remarkably well living up to the challenge. Routine immunization is credited with preventing 2.5 million child deaths every year; 86% of all children received 3 doses of DTP vaccine and at least 1 dose of measles vaccine in 2018. Of course not all is going well with immunization programs, as many countries will miss 2020 coverage targets for routine vaccines and for introduction of new vaccines, and coverage for DTP has not increased in a decade.
      • Peck M
      • Gacic-Dobo M
      • Diallo MS
      • et al.
      Global routine vaccination coverage, 2018.
      Catching children up on vaccinations missed due to COVID-19 and the impending upcoming work of vaccinating children, adolescents, and adults against SARS-CoV-2 infection add substantially to the challenges. Immunization programs need to be strengthened with resources and innovations to achieve the promise and potential of vaccines.
      The World Health Assembly mandated the World Health Organization (WHO) to create the Expanded Program on Immunization (EPI) in 1974. A global public health treasure, EPI is a full-service program implemented by governments of all Member States to bring the benefits of immunization to children throughout the world. Countries’ EPI systems embody the duty that government shares with parents to protect children from vaccine preventable diseases.
      Regardless of country income stratification – high, upper-middle, lower-middle, or low – immunization programs have the central challenge of using their assets to ensure that the right vaccines are made available to target populations safely, effectively, and on time. Programmatic asset capacity and even existence varies by country, and not necessarily in accordance with income stratification. Assets include a national immunization advisory group (NITAG; eg, ACIP is the US NITAG), a vaccine supply chain and network of providers, systems to monitor coverage, safety, and effectiveness of vaccination, and a means to finance the purchase of vaccines and support the immunization workforce and its work.
      As pediatricians, we can see EPI for what it is—a fundamental program for child health and equity. WHO and international partner organizations, including UNICEF, Gavi, and the Bill and Melinda Gates Foundation, support immunization programs for the entire lifecycle of vaccines – development, regulation, recommendation, financing, procurement, and monitoring. Gavi, in particular, has made new and underutilized vaccines that are recommended by WHO and procured through UNICEF affordable to EPI systems in many countries that would otherwise do without.
      Ensuring the availability of safe, affordable, and effective vaccines that families can confidently give to their children is essential, but having vaccines is not enough. As pediatrician Walt Orenstein has famously said, “Vaccines do not save lives – vaccinations do.”
      • Orenstein W
      Vaccines don't save lives. Vaccinations save lives.
      Immunization is a clinical preventive service, delivered one person at a time, quite unlike some other public health interventions such as safe drinking water. Individual children's vaccination status becomes coverage at the population level, and attaining and sustaining high coverage is essential if vaccines are to accomplish public health objectives of control, elimination, or eradication of vaccine preventable diseases.
      I will highlight 3 global efforts to raise and sustain high vaccination coverage – establishing a second year of life vaccination platform, Immunization Information Systems to provide visibility into who needs to be vaccinated, and school record check programs to ensure full vaccination of children entering school.
      The second year of life has always posed a challenge for vaccination – indeed, for decades in the United States, coverage with the first booster dose of DTaP has lagged primary series coverage. A recent UNICEF and WHO study of demographic health surveys conducted in 46 low- and middle-income countries found that a quarter of children missed vaccination opportunities during their second year of life, with a key reason being that there is no vaccination platform after infancy.
      • Hanson CM
      • Mirza I
      • Kumapley R
      • et al.
      Enhancing immunization during second year of life by reducing missed opportunities for vaccinations in 46 countries.
      WHO has published a comprehensive manual for establishing a platform for vaccinations in the second year of life, during which second-dose measles vaccine and booster doses can be given. Key points for the second year of life platform are that vaccination goes beyond infancy, as an increasing number of vaccines are now recommended past 12 months of age; program eligibility for vaccines should therefore extend beyond infancy, so that toddlers late for an infant vaccination are not denied the vaccination; and immunization services in the second year of life can be used as a platform for other essential maternal/child health services. With a strong second year of life platform, therefore, missed infant vaccinations can be given rather than being missed forever.
      Establishing and Strengthening Immunization in the Second Year of Life: Practices for Vaccination Beyond Infancy.
      Immunization Information Systems are in increasing use globally, helping to make the invisible—children in need of vaccination – visible, making it possible to know who needs to be vaccinated and forming the basis of reminder/recall systems. The converse – knowing who is already vaccinated—can bring efficiency to a program, breaking a reliance on large campaigns that may repeatedly vaccinate children already immunized. Immunization Information Systems have long suffered from incompleteness, but by integrating their functions into electronic medical records, redundant data entry can be avoided, and the information systems can help manage children's immunizations.
      A key enabling technology for Immunization Information Systems is the smartphone, with its QR code scanning capability and privacy-ensured connectivity through Internet and 4–5G networks. Most people have a smartphone now, and the arc of technology will almost certainly lead to global ubiquity of smartphones among families. Beyond reminders and immunization record checks, smartphones apps can even check the pedigree and travels of a dose of vaccine administered to an individual child, from manufacturer to clinic to child, making traceable previously invisible information useful to parents and providers.
      School entry vaccination record check programs bring in another child-focused system, the education system, to help ensure that all children have had the opportunity to receive their recommended vaccines. In most countries, schools, collectively, have the only comprehensive lists of all children, since attending school is compulsory in almost every country and is considered a fundamental human right. Record checking strategies vary widely, but at their core is the assessment of vaccination status and the offering of vaccination to children missing one or more doses.
      • Feldstein LR
      • Fox G
      • Shefer A
      • et al.
      School-based delivery of routinely recommended vaccines and opportunities to check vaccination status at school, a global summary, 2008–2017.
      In return for providing a means to check vaccination records of all children, schools are made safer from outbreaks of vaccine preventable diseases. Schools are increasingly being used as vaccination sites, adding more value to partnership between immunization programs and the education system.
      Charting a pathway forward for EPI, WHO, partner organizations, and national immunization programs developed Immunization Agenda 2030, a high-level, comprehensive strategic plan to realize the potential of vaccines through the world's EPI systems. On August 3, 2020, the World Health Assembly endorsed Immunization Agenda 2030, envisioning “a world where everyone, everywhere, at every age, fully benefits from vaccines to improve health and well-being”

      World Health Organization. Immunization agenda 2030: a global strategy to leave no one behind. Available at: www.who.int/immunization/immunization_agenda_2030/en/. Accessed October 12, 2020.

      —a vision that is in perfect alignment with pediatricians’ longstanding effort to make the world a healthier, safer, and more equitable place for children.

      Acknowledgments

      Financial disclosure: This article was published as part of a supplement sponsored by the Centers for Disease Control and Prevention.
      Disclaimer: The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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