Vaccine progress is stalling.
That's the message from a new report issued by the World Health Organization and UNICEF.
The report focuses on the DTP vaccine — the essential vaccine that protects kids against diphtheria, tetanus and pertussis (whooping cough) and that was first licensed in 1949.
The WHO goal is to vaccinate 90 percent of the world's children against DTP, delivered in a series of three shots over three to four months, starting at age 6 weeks. That 90 percent figure is important not only to protect kids from these life-threatening diseases but because the percent of children receiving DTP is a good indicator of how well countries are doing with other vaccinations. It's considered one of the most basic vaccination recommended by WHO and it's the first one children get. Worldwide since 2010, 86 percent of children are receiving all three doses of this routine immunization. One in ten children aren't getting the first dose.
That four percentage point gap might not sound like a lot. But on the national level, it means that 64 countries out of 195 haven't been able to meet the 90 percent target. And many of them have a long way to go. Eight countries — most of them war-torn countries like South Sudan and Syria — haven't been able to vaccinate even 50 percent of kids against DTP.
We spoke with Jean-Marie Okwo-Bele, director of immunization, vaccines and biologicals at the World Health Organization and Robin Nandy, chief of immunizations at UNICEF, to understand the roadblocks to better coverage — and encouraging signs for progress in the future.
War is the enemy
Syria is just one example of how warfare makes vaccinating children harder. Since 2011, the civil war has destroyed hospitals and clinics as well as damaged the supply routes for delivering vaccines to those health facilities left standing. In 2010, Syria's vaccination rate for three doses of DTP was 89 percent but in 2016 had fallen to 61 percent. Of the eight lowest performing countries last year, a number are mired in ongoing conflicts in at least part of the country, including Central African Republic, Chad, Nigeria, South Sudan, Syria and Ukraine. Even after fighting ends, it will take time to rebuild in Syria. It may be years after fighting ends for vaccination rates to get back to pre-war levels, Nandy says.
Sometimes conflict is only part of the problem. The Nigerian government is fighting the militant Islamist group Boko Haram in its northern region, which has an impact on vaccine rates. But other factors contribute to the problem. Although Nigeria is an oil-rich country, more than 60 percent of the country lives in poverty. If the country could eliminate inequity between its richest and poorest populations, it could improve DTP vaccination rates by 40 percent, according to a recent WHO report. Because of these factors, Nigeria has replaced India as the country with the most children unvaccinated for DTP, with 3.4 million children without three DTP doses.
Even high vaccination rates don't mean all kids are protected
In India, 88 percent of children get three doses of DTP. That's nearly meeting the WHO goal. But in urban slums, the vaccination rate can be a lot lower. Those neighborhoods with lots of unimmunized kids often lack other basic health care services. That predicament occurs in many countries with large urban slums — for example, Kenya and Pakistan. "If they're not receiving vaccines, they're probably not getting antibiotics for respiratory diseases," Nandy says. "Pockets of unimmunized children are an indicator of inequity." India is making progress, though, by sending health-care workers into the areas with the lowest vaccination rates.
Even in countries with good health care in urban centers, large swaths of rural areas are often at a disadvantage. People in those remote regions may have to travel miles to see doctors. Delivering vaccine to these locations is hard; health care workers trek there with vaccines stored in portable ice chests, sometimes strapped to their backs. Hot temperatures can kill the part of the vaccine that confers immunity.
Lack of trust can trigger a huge drop
One of the most dramatic examples of the role trust can play can be found in Ukraine. In 2008, a teen boy died after getting his measles and rubella vaccination. Media outlets incorrectly reported that the vaccination caused his death; the government halted vaccination efforts until an investigation was completed. Many parents skipped or delayed vaccinations after this incident. Vaccination rates were 80 to 90 percent for most vaccines in 2008. Today they hover below 50 percent for DTP and other vaccines. "If communities lack trust in services, they won't seek services," Nandy says. The conflict in Eastern Ukraine in the past three years has been a factor in the low rates as well.
But building trust is possible
Ethiopia, for example, has recruited 38,000 health extension workers to improve health-care delivery, including vaccinations, in rural areas. The health workers, drawn from the populations they serve, are beginning to win the trust of those communities, says Nandy. Vaccination rates for the three DTP doses have risen from 61 percent in 2010 to 77 percent in 2016.
Poverty isn't always an obstacle
Tanzania is a relatively poor country but has maintained 85 percent coverage rates for more than 25 years, Okwo-Bele points out. The country has had the political will to make immunizations a priority, and with foreign health aid, has built a well-organized system to deliver vaccines where needed, with trusted community health workers and reliable refrigeration for vaccines.
Newer vaccines are making progress
DTP isn't the only vaccine WHO and UNICEF are watching. Nandy and Okwo-Bele say they are encouraged by the response to the newest vaccines — for pneumococcal pneumonia and rotavirus, which causes diarrhea. Those diseases are among the biggest killers of children under 5 years old. More countries are offering the vaccines and coverage rates in low income countries are steadily improving. According to UNICEF, pneumococcal vaccine coverage was around 75 percent and rotavirus vaccine coverage was around 50 percent in 2012. But it will be important to monitor progress, "so gains made aren't threatened," says Okwo-Bele.
Rina Shaikh-Lesko is a science journalist who writes about medicine, global health and the life sciences. She can be reached @rinawrites