Strengthening Routine Immunizations and Responding to Covid-19

At the Global Vaccine Summit, to be hosted by the United Kingdom on June 4, governments and donor organizations will gather virtually to pledge financial support to enable Gavi, the Vaccine Alliance, to carry out an ambitious agenda over the period between 2021 and 2025. Thanks to Gavi funding, lower- and lower-middle-income countries have made considerable progress over the past two decades in extending immunization services to the world’s poorest and most vulnerable communities. However, as the Covid-19 pandemic extends further into 2020, there is concern that millions of people—those in lower- and lower-middle-income countries, as well as populations living in middle- and upper-income countries—will miss routine immunizations this year as health resources are diverted to outbreak response. With many experts noting that developing and widely disseminating a Covid-19 vaccine represents the best option for controlling the coronavirus outbreak, sustaining and even strengthening routine immunization services now will help improve health conditions and ensure broad demand for, and distribution of, a Covid-19 vaccine, once available.

Q1: How is the Covid-19 pandemic affecting routine immunization coverage?

A1: During the last two decades, countries around the world, especially lower-income and lower-middle-income countries, have made significant progress in improving immunization coverage rates and ensuring their populations have access to vaccines that can prevent deadly diseases. But in some places, immunization coverage has plateaued. One reason is persistent high fertility, particularly in sub-Saharan Africa, where large annual birth cohorts mean governments must invest funds to immunize a greater number of infants and young children each year. Conflicts and natural disasters can also make it difficult to ensure the distribution of immunization services to remote or underserved populations. At the same time, immunization coverage has also stalled due to misinformation, mistrust, and hesitancy about vaccines.

Recent declines in coverage of the measles vaccine, for example, have led to outbreaks of an infectious disease once on the path to global elimination. In 2018, Albania, Czechia, Greece, and the United Kingdom, lost their elimination status, while in 2019, the United States recorded its highest number of measles cases in a quarter-century. In Africa, Madagascar, Somalia, and the Democratic Republic of Congo, have experienced widespread outbreaks. And in Latin America, a region recognized in 2016 for having eliminated measles, Venezuela and Brazil have been especially hard hit. Last year the World Health Organization (WHO) reported that in 2018 more than 140,000 people, primarily children under the age of five, died from measles infection, up from 124,000 estimated deaths in 2017.

Maintaining, much less improving, global immunization coverage rates has become particularly challenging during the Covid-19 outbreak. Health workers and other health resources have been diverted to Covid-19 response, leaving immunization programs understaffed. In other cases, parents are reluctant to take their children to the health clinic, fearful of being exposed to Covid-19. Even where demand for immunizations remains high, vaccines are not always available. The dramatic slowdown of international air travel in March and April has broken some vaccine supply chains and limited the delivery of new vaccines and delivery equipment to government health ministries.

Given the Covid-19 crisis, it is estimated that at least 13.5 million people will miss routine immunizations this year. The WHO’s Strategic Advisory Group of Experts (SAGE) has advised halting all mass immunization campaigns for a period of time, and the Global Polio Eradication Initiative (GPEI) has also suspended its operations, putting the achievement of that long-held goal even further in the future as polio program assets are repurposed for Covid-19 response. The WHO has issued interim guidance to help countries continue or plan to catch up with their routine immunizations once the Covid-19 crisis eases.

If routine immunization coverage rates continue to decline, it is likely that there will be intensified outbreaks of measles, diphtheria, pertussis, and other vaccine-preventable diseases, such as pneumococcal disease, in the near term. This was the case in West Africa after the Ebola outbreak in 2014-2015 shifted resources and attention away from routine health services, such as maternal and child health, to emergency response. In the longer term, outbreaks of vaccine-preventable disease, along with the urgency of conducting catch-up campaigns, will almost certainly cost more and create greater burdens on already stressed health systems.

Q2: What efforts are currently in play to improve immunization access globally?

A2: As the global community wraps up the Decade of Vaccines (2010-2020), a new WHO-led plan, Immunization Agenda 2030 (IA2030), highlights the importance of equitable access to immunizations for populations in all countries. Envisioning “a world where everyone, everywhere, at every age, fully benefits from vaccines to improve health and well-being,” IA2030 is meant to replace the Global Vaccine Action Plan (GVAP) and to provide guidance to all countries regarding ways to improve access to immunization programs.

Developed through a “bottom-up,” consultative process, IA2030 is led by the WHO. It complements the work of Gavi, the Vaccine Alliance, which focuses on making vaccines available and affordable to the world’s lowest-income countries. Since 2000, Gavi, a public-private partnership launched at the World Economic Forum, has worked to help eligible countries—currently those with an annual gross national income (GNI) per capita of $1,630 or less—procure vaccines at low cost. Gavi also provides eligible countries with grants to strengthen health systems and build appropriate immunization systems for vaccine delivery.

Q3: What is the global vaccine summit?

A3: At the Global Vaccine Summit 2020, which convenes virtually in London on Thursday, June 4, governments, foundations, and the private sector will pledge support to enable Gavi to carry out its next phase of work during the 2021-2025 period. It is the third replenishment at which Gavi is seeking support, and it is the second to be hosted by the United Kingdom. For this pledging conference, Gavi is asking donors to contribute at least $7.4 billion over the next five years so that the Alliance can carry out an ambitious agenda of improving access to routine immunizations in eligible countries. Gavi makes emergency stockpiles of vaccine for diseases, such as Ebola, Yellow Fever, and Cholera, available to eligible countries, as well. To date, governments including the United States, Norway, the United Kingdom, Spain, Canada, Ireland, Italy, Saudi Arabia, New Zealand, and Japan, along with private companies such as TikTok, have pledged support for Gavi’s work in the next phase. 

During the summit, Gavi also plans to launch an Advance Market Commitment (AMC) with a goal of generating at least $2 billion in funds to support the distribution of a Covid-19 vaccine, once available, to eligible countries. Under the AMC, Gavi proposes to provide funds to manufacturers around the world to help them procure essential raw materials and expand their capacity to produce vaccines at large scale. Gavi also proposes to incentivize the production of a Covid-19 vaccine by arranging in advance for the bulk purchase and distribution of a product, once approved, to Gavi-eligible countries.

Q4: What role can a vaccine play in responding to Covid-19?

A4: Most experts argue a vaccine to prevent infection with Covid-19 will be the most effective way to achieve population immunity to the novel coronavirus and end the current outbreak. More than 100 companies and research consortia involving academia, the private sector, and government science agencies report that they are actively investigating a Covid-19 vaccine, and some of those have advanced to human trials.

Still, vaccine research is expensive, time-consuming, and can face many challenges. The development timeline for relatively recent vaccines, such as that for human papillomavirus (HPV), was more than a decade. Even the Ebola vaccine, Ervebo, which was authorized by the European Commission and then pre-qualified by the WHO in the fall of 2019, took five years to bring to market, although it was deployed for experimental use during the outbreak in the Democratic Republic of Congo prior to approval. With an accelerated research timeline and investments in manufacturing, even as research is ongoing, some experts are hopeful a Covid-19 product could be available by early 2021 while cautioning that any products must be fully tested for safety and efficacy. One challenge is that there are not currently any vaccines to protect against coronaviruses on the market, although there has been previous research focused on developing vaccines for other coronaviruses, including SARS and MERS.

Several institutions and mechanisms are currently funding Covid-19 vaccine research: these include the Coalition for Epidemic Preparedness Innovations (CEPI), which was established in 2017 to “stimulate and accelerate the development of vaccines against emerging infectious diseases and enable access to these vaccines for people during outbreaks.” A public-private partnership, CEPI has committed $384 million for research on one or more promising coronavirus vaccines. The International Financial Facility for Immunizations (IFFIm) is connected to Gavi and receives long-term financial commitments from donors to support efforts related to vaccine research and production. Also, the European Commission is supporting a pledging drive to raise up to €7.5 billion for the Access to Covid-19 Tools Accelerator (ACT) to support work on Covid-19 vaccines and other diagnostic and therapeutic measures. 

Q5: Why is it important to ensure strong immunization programs are in place once a Covid-19 vaccine becomes available?

A5: It is essential to maintain a global focus on routine immunizations, both to protect infants and young children from vaccine-preventable diseases and to prevent outbreaks from developing when health systems in lower-, middle-, and high-income countries alike are already stressed because of Covid-19. Having high-performing immunization systems in place will also help ensure the delivery of a Covid-19 vaccine, once one becomes available, to the neediest and most vulnerable populations, including health workers, the elderly, and those with chronic health conditions.

Taking the time now to ensure communities understand the role of vaccines in protecting health and feel confident in the products that may be made available to them is also important. A recent survey, for example, suggested that only 49 percent of the population in the United States, would be willing to receive a Covid-19 vaccine once available, with 20 percent saying they would not want to get the vaccine out of concerns related to safety and side effects.

Katherine E. Bliss is a senior fellow with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.

This Critical Questions is made possible with the generous support from Bill & Melinda Gates Foundation.

Critical Questions is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

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Katherine E. Bliss
Senior Fellow and Director, Immunizations and Health Systems Resilience, Global Health Policy Center