Opinion article |

Science Omega: Vaccines without barriers

Author: Kate Elder, Vaccines Policy Advisor

In May 2011, Bill Gates unveiled the Decade of Vaccines to the United Nations in Geneva. Aimed at reducing deaths due to vaccine-preventable diseases, and expanding the benefits of immunisation to all, particularly in low and middle-income countries, this initiative has catalysed a new momentum within the global health community.

Médecins Sans Frontières (MSF) repeatedly responds to outbreaks of vaccine-preventable disease, vaccinating over five million people on average each year against measles alone. With over 112 million children born over the past five years who have missed out on being protected from killer diseases, this new momentum is as welcome as it is necessary.

The Global Vaccine Action Plan provides the blueprint for implementing the Decade of Vaccines, and will serve as an overarching framework for the activities of the years ahead. The plan has already been endorsed by the 194 member states of the World Health Organization (WHO). In May, countries will be asked to greenlight its targets and the indicators by which we will be able to judge its success.

Closely measuring progress will be of the utmost importance in the decade ahead, and it’s critical we set the right targets so that the global community’s impetus on vaccines is well-directed.

MSF believe that there are two pressing issues that aren’t being prioritised enough.

The first is vaccine prices. In 10 years, the cost of vaccinating a child with the basic WHO-recommended EPI package has soared by 2,700 per cent. In 2001, it cost governments $1.37 to vaccinate a child with the EPI package of vaccines; as newer, more expensive vaccines have been added, the cost today reaches $38.80. Indeed, this is merely the sum of the lowest possible prices available to developing countries; most countries are paying much more for their package of vaccines.

Middle-income countries, home to more than half of the world’s poorest people, bear the full brunt of higher vaccine prices, as they pay for vaccines without foreign assistance, but countries that are considerably poorer are also set to be hit. As they reach a certain income per capita, countries lose donor support. The aid community euphemistically calls this ‘graduating’ while, in 2009, a Ministry of Health representative from Sudan better termed it ‘expulsion’. Honduras, for example, faces a staggering 1,000 per cent jump in the cost of its vaccination programme when it ‘graduates’ from donor support at the end of 2015.

The rising cost of vaccinating a child due to the high price of newer vaccines is a considerable concern – so much so that the very sustainability of immunisation programmes is jeopardised.

Yet the issue of vaccine prices is scarcely addressed in the Global Vaccine Action Plan. The plan for the next 10 years has no target to monitor the price of vaccines, or goal to see them reduced. In a context of increasingly constrained international donor financing, ensuring every euro of taxpayer money goes as far as possible is paramount. The Decade of Vaccines is estimated to cost more than $50bn, and a large part of that will be swallowed up by the pharmaceutical companies selling the vaccines. The omission of a target to bring down prices is glaring.

The second issue concerns vaccines that are available today, and their suitability for use in developing countries. Vaccines must be kept in the ‘cold chain’ – in a constant state between 2 and 8°C – at every step of their journey from the manufacturing plant all the way to the patient.

In countries where the infrastructure is poor and distances huge, where the children unreached by immunisation live in remote and close to inaccessible communities, where electricity is unreliable, and in some contexts, where outside temperatures hit over 40°C, there are huge logistical challenges in transporting vaccines at a constant cool temperature.

Thanks to the generosity of our donors, MSF can access the large storage facilities needed for the bulky vaccines; the fridges and the icepacks; the motorbikes to get them out to the villages for each dose in the immunisation schedule; and the logisticians with the expertise to oversee the operation. But for countries with depleted health infrastructures and minimal human resources, achieving and sustaining high levels of coverage with vaccines that require refrigeration is close to impossible.

The tools that we currently have were designed for developed countries, where such logistical challenges don’t exist, or are surmountable. We need vaccines that are made with developing country settings in mind. The vaccine we need is one that doesn’t require a cold chain. It’s one that’s small and easy to transport. It would give maximum protection in just one dose, so that repeat visits or retracing of children wouldn’t be needed. It would target the disease epidemiology found in developing countries and not be a vaccine developed for use in Europe and the US and rolled-out to Africa as an afterthought, regardless of whether the strains of the disease are different. It would be needle-free, and come instead as oral drops so that almost anyone could administer it.

Here too, our plan for the next 10 years is astoundingly lacking in ambition. It aims for just one new adapted vaccine delivery technology to be approved and implemented by 2020. With many novel technologies already in the pipeline we should be aiming higher. We need to be setting this as a priority, and committing ourselves to deliver.

In April, Bill Gates and the Crown Prince of Abu Dhabi will be hosting a vaccines summit during the first-ever World Immunization Week. Gates and the Crown Prince hope to highlight the critical need to expand the reach of vaccines and drive resources towards achieving this ambition. MSF shares the same goal. But to be successful, we will need to address the two issues that prevent children from accessing life-saving vaccines.