By David R. Curry
Villagers line up to be vaccinated against Smallpox at an outdoor clinic, Côte d'Ivoire, 1970s. From the WHO Archives.
In February, 2012, I participated in the WHO Extraordinary SAGE meeting in Geneva, called to review the Global Vaccine Action Plan (GVAP) being developed by the Decade of Vaccines Collaboration (DoVC). On the flight back to the U.S., I was reflecting on the continuing challenge of identifying and scoping "game changers" in the GVAP to help realize the DoV’s ambitious vision:
The vision for the DoV is a world in which all individuals and communities enjoy lives free from vaccine-preventable diseases. Its mission is to extend, by 2020 and beyond, the full benefits of immunization to all people, regardless of where they are born, who they are, or where they live.
We need “game changers” because of the scale of the challenge, to be sure. But I was also reflecting on the history of global immunization strategies and that we have faced the same core challenges for generations.
Having arrived early for the SAGE meeting, I spent a day in the WHO Archives pursuing the broad question of when the WHO first considered anything like a global immunization strategy, and at least one other reference point for perspective. Two original documents caught my attention.
The first was a report from what appears to be the first expert consultation on this theme: the first session of the Expert Committee on Maternal and Child Health, Geneva, January 1949. The session title was Immunization Against Principal Communicable Diseases of Childhood - Plan for an International Program (WHO/MCH/5).
The meeting report surveys the then-current knowledge on immunization – informed by WWII – and includes a key recommendation for convening an "international expert conference on immunization procedures as soon as possible. This conference should bring together epidemiologists, paediatricians, heads of child-health services, and experts responsible for the preparation of vaccines in state and other official laboratories and institutes. The conference should discuss the use of the newer techniques for producing the more effective vaccines (e.g. pertussis vaccine) and plans for their widespread application in immunization programs..." The proposed conference was later convened as a result of a resolution adopted at the Second World Health Assembly.
But in the meeting report, the assessment of immunization and its challenges in 1949 (as thinking about an international program was just underway) was alarmingly "current":
"Where immunization programmes have failed, the main reasons for such failure have been 1) a false sense of security when the incidence of these diseases happened to be low, although the population has not yet been adequately immunized; 2) Lack of adequate health education of the public; 3) Insufficient information among the medical professions as regards new immunization procedures; 4) Reluctance to use auxiliary personnel for mass immunization; 6) Lack of appropriate immunization agents [vaccines]; and 7) Lack of appropriate legislation and funds for immunization programmes."
A companion recommendation was the release of a circular letter by WHO to all WHA members surveying "active immunization" programmes, including an inventory of which diseases and what age groups might be involved in either "advocated" or "compulsory" immunization, whether the country's programme was "assisted by an organized public information campaign," and whether the public is "generally eager for immunization, passive, or reluctant..."
The second reference point comes from a 1974 Consultation on the WHO Expanded Programme on Immunization held at Geneva (VIR/74.15), obviously very early in the EPI era. The report notes:
"...most diseases against which vaccines are available are still uncontrolled in virtually all developing countries. The principal problems are a) lack of trained personnel (and often the idea that only physicians or highly trained nurses should administer vaccines); b) use of complicated immunization schedules appropriate to developed countries but which do not recognize the local epidemiological and administrative realities of the developing world; c) the high cost of equipment and difficulties of maintenance of e.g. transport, refrigeration and jet injectors; d) the cost of many of the vaccines, and e) restrictions on the production of some vaccines because vaccine strains or methods have been patented."
Later in the report, two additional factors around "shortcomings in immunization activities" caught my attention: that “cost benefit and cost effectiveness analyses are either not appreciated by health planners and administrators, or have not been undertaken...” and that “illiteracy and poorly developed public information media result in the lack of public understanding of the need for immunization..."
Finally, this 20-page analysis concludes with a series of recommendations for the year ahead, asserting: "Immunization must be recognized as an essential and permanent programme for the control of communicable diseases and must be a primordial responsibility of the country concerned. The role of the WHO is to stimulate countries to set up immunization programmes and to assist them in doing so..."
These two reference points – from over 60 years ago and almost 40 years ago – are, in a sense, humbling. But they also are a fresh call-to-action. Now is the time to focus our energies and stretch our collective imagination to complete the GVAP with critical game changers, and boldly implement it in the decade-plus ahead. Now is the time for us all to commit our generation to realize the DoV vision.
David R. Curry is Executive Director of the Center for Vaccine Ethics and Policy, a joint program of the Penn Center for Bioethics, the Wistar Institute Vaccine Center, the Vaccine Education Center of the Children’s Hospital of Philadelphia.