Health - Commentary

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The 'missing' vaccines

It should be one of the biggest news stories of all time: the prospect of vaccines that could save the lives of 8 million children each year, or 22,000 children each and every day. Instead, there is silence. Could the reason be that these 8 million are, overwhelmingly, the unseen, unheard children of the poor?

The unconscionable fact is that some vaccines already on the market have never even made it to their intended targets. The antigen for hepatitis B -- a disease that kills around 1 million people each year -- has been available since the early 1980s. But many of the countries that need it, including Azerbaijan, Benin, Cambodia, Tanzania and Viet Nam, cannot afford this vaccine, even though its cost has plunged from $150 to less than $1 per dose.

Yellow fever is again menacing Africa and Latin America, with Gabon, Ghana and Nigeria suffering outbreaks in 1994, and Liberia and Peru in 1995. In each case, expensive emergency immunization efforts were needed to stop the spread of the disease.

Five years ago, public health officials recommended that the hepatitis B and yellow fever vaccinations be added to the basic immunization package, along with nutritional supplements of vitamin A. Yet few of the 34 at-risk countries in Africa have been able to include the yellow fever vaccine in their immunization programmes, even at the UNICEF-discounted price of only 17 cents. As demonstrated in 1994 and 1995, funds can be found to contain the disease when it begins to spread -- but not, apparently, to keep it from getting into circulation in the first place.

Other vaccines falling into cost-benefit quagmires are those against Haemophilus influenzae type B (Hib disease), a leading cause of pneumonia and meningitis among young children, and rotavirus, the diarrhoea-inducing microbe blamed for the yearly deaths of almost 1 million children.

Such problems cast a shadow over prospects for two future life-savers: vaccines against malaria and HIV/AIDS. The development of a malaria antigen is proving both slow and costly, and work on a vaccine against HIV infection is still not receiving the support it requires. The problems with both vaccines may in part be due to the reluctance of manufacturers. They face daunting scientific challenges compounded by financial and political concerns about vaccines almost certain to be beyond the reach of the countries that need them most.

Where we stand

The success of the global immunization effort is unprecedented. But we need to take a closer look at this achievement. The tremendous gains against polio, for example, are tempered by the continuing threat of other diseases, such as measles.

Polio is without question the star of the current international immunization effort. Only 3,234 cases were reported worldwide in 1997, down from 23,000 cases seven years earlier, and the western hemisphere has been polio-free for seven years. Although underreporting remains a problem, it is clear that polio is on the run. In 1997 alone, more than half the world's children under the age of 5 were vaccinated during massive campaigns that, along with routine immunization efforts, may wipe the disease from the face of the planet within the next two years.

Such campaigns also galvanize political commitment, bring in extra funding and increase awareness of the importance of routine immunization and other basic child health measures. For instance, at least 34 countries use National Immunization Days as an opportunity to distribute vitamin A supplements widely. Boosting vitamin A levels in children who are deficient in this vital micronutrient can cut child deaths by about one quarter.

But there is another immunization story, a largely untold one. It is the story of the never-ending battle to raise and maintain basic immunization rates; to build the capacity of local and national systems so they can vaccinate one year's generation of 130 million babies on five separate occasions, then do it all over again the next year, and the next; and to convince families and communities that starting and continuing immunization is crucial to their children's health.

The relentless attacks of measles, which kills more children than any other disease currently preventable through vaccination, give some idea of the scale both of the progress already made and the problems that remain. The overall measles vaccination rate for developing countries now hovers at 77 per cent of children under the age of 1, and two thirds of all countries have already reached the year 2000 goal of cutting the number of measles deaths by at least 95 per cent.

But measles continues to thrive in the cities of Africa and Asia, especially in deprived neighbourhoods. Just 20 countries now account for 85 per cent of measles deaths of children under the age of 5. That means about 722,000 children are dying in those countries each year, half of them in Africa and 230,000 in India alone. In addition, measles immunization coverage has remained static or slipped in 32 of the 44 poorest countries since 1990, including Burundi (25 per cent decline in coverage), Papua New Guinea and Yemen (23 per cent), Malawi (14 per cent), Benin (13 per cent) and Mali (12 per cent).

Yet some of the poorest nations on earth are actually making the greatest strides. Cambodia, for example, has more than doubled its measles immunization rate, from just 34 per cent in 1990 to 72 per cent in 1996. Guinea's measles coverage rate stands at 61 per cent, compared to only 18 per cent in 1990.

Upcoming vaccines could save 8 million lives a year -- but at a price.

These gains show what can be achieved when the national will is truly committed and when strong one-off campaigns are backed by vigorous routine immunization. Thanks to concerted efforts in the 20 hardest-hit countries, the global neonatal tetanus death toll has fallen from 400,000 to 280,000 in just seven years.

There is a message here, not only for developing countries, but for the industrialized world.

After nearly eliminating diphtheria, the countries of the former Soviet Union were rocked by epidemics in the early 1990s, sparked by plunging economies, armed conflict, irregular supplies of vaccines and massive population movements from the countryside to the cities. The number of cases soared, from under 2,000 across the region in 1990, to over 47,000 by 1994. Soon after, the epidemic spread to other European countries, including Bulgaria, Germany, Norway and Poland. The international community had to step in, and all the countries of the former Soviet Union except Belarus and the Russian Federation still depend on outside assistance for vaccines. The painful lesson is that if we let up our efforts for a minute, we pay for a very long time.

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