UN reports 21.8 million infants weren’t vaccinated in 2013

Nearly 22 million infants around the world were not vaccinated last year that should have been, according to a report released last week by the World Health Organization and UNICEF. The startling number underscores the need for innovations in vaccination storage and a critical re-think of existing vaccine aid programs, health advocates said.

Though more than 111 million infants were vaccinated last year, WHO estimates that figure accounts for only 84 percent of the world’s children – and in fact, some experts say the proportion could be even lower.

Most of the children who don’t receive vaccines are from countries in Africa and South East Asia, even though international aid has been directed there for years. India alone accounted for 6.9 million unvaccinated infants. Loopholes in economic support and governmental policies make it difficult for vaccines to reach these countries, but they could be rectified, say advocacy and humanitarian aid groups.

“We need to critically see how we are supporting the vaccine process,” said Kate Elder, the vaccines policy advisor for the Médecins Sans Frontières (MSF) Access Campaign. “We need the tools to take vaccines to some of the places that are off the electrical grid – such as more heat stable vaccines – but these are yet not available to health workers.”

The vaccination numbers in 2013 fall short of the goal set by the Global Vaccine Action Plan, a campaign endorsed by the global health community in 2012. That plan, according to WHO, has a target of achieving 90 percent coverage for all vaccines by 2020 in order to save millions of lives.

“We face a challenge in closing the gap between 84 percent and 90 percent,” said Michel Zaffran, coordinator of WHO’s Expanded Programme on Immunization, in a press release last week. “It is hard for [countries] to reach all children including those in remote areas or in urban slums.”

However, the ‘84 percent’ figure does not even give the true picture of the status of immunization in the world, said Eric Starbuck, advisor for Save The Children’s department for Health & Nutrition. Rather, it is a proxy measurement that uses coverage of one trivalent vaccine – the third dose of a vaccine called DTP that protects against diphtheria, tetanus, and pertussis – as an estimate of immunization coverage.

“That is a summary kind of estimate that’s been used for a long time,” he said. “It only tells part of the story.”

If the WHO tracked coverage for all 11 vaccines now recommended for all infants, the percentage “would be a much, much lower figure,” Starbuck said.

Why aren’t children getting vaccines? 

Experts say the reasons why children miss critical vaccines are multi-layered.

While weak health systems are the primary reason for low vaccine coverage in developing countries, a major factor is the difficulty in reaching these children – many areas aren’t accessible due to poor roads, are mired in political conflict, or simply have no source for electricity, creating logistical challenges in carrying and storing vaccines, said Tamara Kummer, spokesperson for UNICEF’s Immunization department.

Currently, vaccines need to be stored at cold temperatures up until the dose is actually administered to a child. This becomes especially hard in countries with no transport facilities or electricity. UNICEF has introduced solar powered refrigerators in some countries, but it is still a challenge to transport the vaccines in cold temperatures in tropical areas, said Kummer. However, recent research indicates that some vaccines could be stored outside these cold temperatures, and experts are urging manufacturers to study this approach.

Aid can help improve the supply chain for vaccines, but even how aid is decided for some of these countries, is a problem, said MSF’s Elder.

For instance, the GAVI Alliance – a public-private partnership that funds vaccines for over 70 of the world's poorest countries – will be phasing out Nigeria from its vaccination aid program because the country has reached a higher economic level. This is despite the fact only 58 percent of Nigerian children received the third dose of the DTP vaccination in 2013, according to WHO figures.

“It is not enough to say that since a country has hit a critical economic threshold they no longer need this aid… GAVI needs to more critically think of the parameters used to make this decision,” said Elder. “Many of these countries are only wealthy on paper but their programmatic development hasn't been at the same pace, nor do they have the adequate resources to absorb the high price of new vaccines.”

Another concern is that WHO immunization recommendations are not always implemented, such as completing a child's vaccination series even if they are over one year of age. Many times, it could be because the recommendations aren’t communicated to the country’s leaders in charge of immunization, she said.

Even the kind of aid made available to these countries could be a reason, said Elder. For instance, GAVI only purchases vaccines recommended by WHO for children up to one year of age, she said.

The expense of some of these vaccines is also a hurdle, especially for middle-income countries that don't receive much aid. UNICEF purchases vaccines for one-third of the world’s children but newer vaccines for viruses like rotavirus, which can cause severe diarrhea, and pneumococcal disease, which can cause pneumonia, are more costly, said the agency’s spokesperson Kummer. Diarrhea and pneumonia are the top causes of death among children in the world.

Cultural barriers too pose a challenge. For instance in Yemen, female vaccinators have easier access to mothers who are primary caregivers, said Kummer. In remote areas of some countries like Congo, lack of information can create vaccine-hesitancy, she said.

A report released by WHO earlier this year, estimates that approximately 1.5 million children died last year from diseases preventable by vaccines currently recommended by WHO.

“Keeping immunization at the top of global health concerns is essential. Currently most governments do not identify funding immunization programs as a priority area,” said Kummer.

“Sustainability and predictability of funding is crucial,” she said. “One in five kids is not getting vaccinated and that’s not acceptable.”

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