World Bank Immunization at a Glance

Why is immunisation of high priority?

Immunisation deserves high priority, especially in developing countries, for three main reasons:

• Vaccine-preventable diseases disproportionately affect the poorest fifth of the population;
• Immunisation is among the most cost-effective health interventions, has had a major impact in reducing the burden of disease, and the benefits are public goods; and
• Newer vaccines, and those under development, have the potential to prevent diseases, e.g., tuberculosis, malaria, and human immuniodeficiency virus (HIV), that currently cause an enormous burden of disease.

Communicable diseases, many of which are vaccine-preventable, account for 77% of the mortality gap and 79% of the disability-adjusted life years (DALY) gap, between the world's poorest and richest 20%.

The Expanded Programme on Immunisation (EPI), targeting mainly six communicable diseases of childhood, reduced the share of these six diseases in the total burden of disease among children under five from about 23% in the mid-1970s, to less than 10% in 2000. To fully immunise a child against the six diseases costs about US$17, making immunisation one of hte most affordable interventions available. Most vaccines cost under US$50 per DALY gained.

Malaria, tuberculosis, and HIV are responsible for more than five million deaths each year, and all are potentially preventable by vaccines. Rapid scientific progress suggests that an effective vaccine is likely to be available for at least one of these diseases in the next decade.

The gains from additional investments in immunisation services and research and development (R & D) for new vaccines include:

• Narrowing the burden of disease gap between the richest and poorest segments of the population;
• Contributing to health sector reform and development efforts;
• Savings of $1.5 billion annually from completing the eradication of polio;
• Substantial reduction in the burden of disease by making effective, under-used vaccines widely available, e.g., vaccines against Hepatitis B, Haemophilus influenzae type b, and yellow fever;
• Reducing the burden of disease from conditions such as Vitamin A and iodine deficiencies, by expanding the coverage of these interventions as components in immunisation services, in countries where they are highly prevalent.

Immunisation is acknowledged to be among the most cost-effective and highest-impact health interventions. Nearly 3 million deaths are prevented each year by immunisation, and an even greater amount of illness and disablility. An additional 3 million deaths a year could be prevented by existing vaccines.

What to do about Immunisation

The information below summarizes the core immunisation interventions, the intended beneficiaries, and key indicators to track achievement of objectives

Reduce vaccine-preventable disease and disability

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Objectives: Prevent six communicable diseases of childhood as well as tetanus in adulthood, including maternal tetanus

Core Interventions: The EPI package of vaccines against diptheria, tetanus, pertussis (whooping cough), polio, measles, tuberculosis, and Hepatitis B

The EPI immunisation schedule* is:

• Birth - BCG (TB), OPV-O (polio)
• 6 weeks - DTP-1 (diptheria, tetanus and pertussis), OPV-1, Hep B-1
• 10 weeks - DTP-2, OPV-2, Hep B-2
• 14 weeks - DTP-3, OPV-3, Hep B-3
• 9 months - Measles
• Women of reproductive age - 2 doses tetanus toxoid

* Dosage and timing of immunisation may vary slightly in some countries.

Beneficiaries/Target Groups

Children under five and women in the reproductive age group

Indicators

• Reduction in vaccine preventable deaths
• % of children under 12 months fully immunised for DTP
• % of children under 12 months immunised for measles
• % of districts that have achieved 80% coverage

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Objectives: Prevent other selected diseases, where they are causing a large disease burden

Core Interventions: Introduce or scale up under-used vaccines, such as those against Hepatitis B, Haemophilus influenzae type b, and yellow fever

Beneficiaries/Target Groups:Target groups very according to the epidemiological situation and program implementation capacity: usually infants for Hepatitis B and for Haemophilus influenzae type b, and people of all age groups living in countries at risk for yellow fever.

Indicators: % of target group immunised against each selected diesease

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Objectives: Reduce vaccine-preventable diseases and major associated conditions

Core Interventions: Include vitamin A supplements with routine immunisation visits where this deficiency is prevalent: for post-partum mothers (within 60 days of birth) and twice yearly for children 6-59 months; vitamin A can be added to mass immunisation campaigns (such as polio NIDs, measles campaigns, Child Health Days, vitamin A deficiency and other severe severe health problems (see Nutrition at a Glance).

Beneficiaries/Target Groups: Susceptible groups, especially young children and post-partum women

Indicators:

• % of children, 6-59 months, receiving vitamin A supplements
• prevalence of night-blindness in the population (symptom of vitamin A deficiency)

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Simplified assessment of national immunisation services

The following questions are intended to provide a quick overview of national immunisation systems. Answers to the questions should be readily available from the Ministry of Health (MOH) or World Health Organisation (WHO). A "no" answer to any question indicates that corrective action is needed (including possible World Bank support).

Infrastructure

1. Is there an individual in the MOH designated with responsibility and authority to achieve immunisation system goals?
2. Is there a multi-year plan of action for the immunisation services specifying both vaccine coverage and disease reduction goals?
3. Is there a line item in the MOH budget to support the immunisation services?
4. Are the immunisation services reaching at least 80% of children nation-wide?
5. Is the vaccine used of assured quality (e.g., procured from a pre-qualified source or through UNICEF, or regulated by an independent and fully functional National Regulatory Authority)?
6. Has an injection practices assessment ever been conducted? If so, have the findings led to changes in policy (e.g., WHO-UNICEF-UNFPA joint policy statement WHO/V&B/99.25 on the used of auto-disable syringes in immunisatoin services and the gradual phasing out of standard disposable and sterile syringes)?
7. Is the vaccine management system adequate (e.g., stock management, cold chain, wastage, use of vaccine vial monitors and other indicators)?
8. Are opportunities to integrate other health interventions (such as vitamin A) with immunisation services, being used effectively?
9. Do the MOH staff responsible for immunisation services at district-level receive training and refresher training regulary (i.e., does the MOH have a human resources development strategy for immunisation services)?
10. Is there a communications strategy and an implementation plan for raising awareness about the need for immunisation services?
    
    
    

    Disease prevention/control
    
    
    

11. Is the country on track to achieve polio eradication?
12. Is the surveillance system functioning well (e.g., standard case definition in use, at least 80% completeness of reporting from established reporting sites, and feedback information being provided by the central levels to peripheral levels on system performance)?
    
    
    

    Introduction of new vaccines
    
    
    

13. Do estimates of the disease burden for Hepatitis B, yellow fever, and Haemophilus influenzae type b exists or are there plans to carry out disease burden studies?
14. Does the multi-year immunisation plan include a plan and funding for introducing new vaccines?

Do's and don'ts in national immunisation systems:

• DO take advantage of the potential of immunisation to strengthen and reform the health system, e.g., by facilitating decentralization, and strengthening surveillance systems, and DON'T make it a vertical program.
• DO focus on strengthening routine immunisation, but DON'T forget that supplementary immunisation campaigns are important to mobilize communities and achieve certain accelerated disease control initiatives of international importance.
• DO take advatage of the high degree of national and international collaboration and ownership of immunisation as a good model for overall health sector development.
• DON'T forget that NGOs and the private sector are key participants in immunisation coalitions: for social mobilization, in public-private partnerships for vaccine R & D, and for giving immunisations.
• DON'T assume that vaccines for developing countries will be developed, marketed, and used, without a major international effort, like the one pioneered by WHO and UNICEF, and being extended by the Global Alliance of Vaccines and Immunisation (GAVI).
• DO remember the importance of high quality immunisation coverage data, now a key indicator for Poverty Reduction Strategy Papers (PRSPs), and an important component of debt relief (HIPC) efforts.
• DO remember that a continuous supply of vaccines of assured quality is essential.
• DON'T forget that managerial skiils are essential, for example, to maintain the cold chain, supervise staff, plan resource mobilization, etc.
• DO seek opportunities for immunisation to be governments, and in World Bank country assistance strategies; this helps to extend discussions to finance and planning ministries which play a key role in financial sustainability.
• DO take advantage of the fact that immunisation is one of the interventions in the Integrated Management of Childhood Illness (IMCI) package.
• DO remember the importance of reliable surveillance to assess the overall impact of immunisation systems and to identify outbreaks, areas of high-risk, and/or weak system performance.

Resources ready to help with immunisation projects

• World Bank Regional Immunisation focal points (Africa - Christy Hanson; EAP - Puti Marsoeki; ECA - Nedim Jaganjac; LAC - Ruth Levine; MENA - Maryse Pierre-Louis; SAR - Benjamin Loevinsohn) and the Anchor (Amie Batson, and Joe Naimoli, CDC Secondee), who can make available technical information, technical assistance, and funds for studies and project preparation
• GAVI: Amie Batson (Financing Task Force co-chair), Laura Cooley (Advocacy Task Force) or Tony Measham (Country Coordination Task Force) for contacts and resources
• Bank-financed immunisation projects recommended for adaptation in other settings: the FY 1999 Bolivia Health Sector Reform project, and the FY 2000 India Immunisation Strengthening project

Key web sites

• GAVI: http://www.vaccinealliance.org
• The Bill and Melinda Gates Children's Vaccine Program at PATH: http://www.ChildrensVaccine.org
• WHO: http://www.who.int/vaccines
• Centers for Disease Control and Prevention: http://www.cdc.gov/NIP
• World Bank: http://www.worldbank.org/vaccines`

Key references

• S.A. Plotkin, Orenstein, W.A., eds. Vaccines, Third edition. W.B. Saunders, Philadelphia, 1999.
• A.R. Hinman, "Eradication of vaccine-preventable diseases", in Fielding, J., ed, Annual Review of Public Health, 20:211-229, 1999.
• William Foege, "The Power of Immunisation", in The Progress of Nations, 2000, UNICEF, New York, pp 19-21.
• WHO, Product Information Sheets, WHO/V&B/00.13, 2000.
• WHO, Safety of injection: WHO-UNICEF-UNFPA Joint Statement on the use of auto-disable syringes in immunisation services, WHO/V&B/99.25, 1999.
• Integrating Vitamin A with Immunisation: An Information and Training Package (A CD-ROM produced by WHO and Helen Keller International, 2000).

Expanded versions of the "At a glance" series, with e-linkages to resources and more information, are available on the World Bank Health-Nutrition-Population web site: http://www.worldbank.org/hnp