Although vaccines save millions of lives each year and protect millions more from severe illness, tens of millions of people worldwide have not received the vaccines they need to be fully protected against vaccine-preventable diseases. Reaching these people, mostly children, requires cheap, easy-to-use vaccines adapted to hot climates and low-resource settings. Doctors Without Borders/Médecins Sans Frontières (MSF) vaccinates many millions of people every year, often in response to disease outbreaks, in some of the most precarious places in the world.
Today’s vaccines can protect against 26 potentially deadly infections. Of these, 11 are considered essential childhood vaccines that should be given according to a defined schedule during routine primary care, starting from infancy and extending into early childhood. Others, such as the meningitis and cholera vaccines, are used in high-risk regions to protect people of all ages against outbreak diseases.
As new vaccines are developed for other deadly childhood diseases, it’s crucial to add them into the basic vaccine package. But there are many challenges in getting these life-saving vaccines to all children that need them.
Routine childhood vaccination
Traditionally, the routine immunizations recommended by the World Health Organization were: diphtheria, pertussis (whooping cough), tetanus, tuberculosis, measles, and polio. The past decade has seen new vaccines against hepatitis B, haemophilus influenza type B, meningitis, pneumonia, and diarrhea added to the recommended package.
Global health organizations like UNICEF and Gavi have greatly boosted these programs. But some of the world’s most vulnerable children are not sharing in these gains—in 2016, approximately 19.5 million didn’t receive any routine immunizations at all. Around 60% of these children live in 10 countries: Angola, Brazil, Democratic Republic of Congo, Ethiopia, India, Indonesia, Iraq, Nigeria, Pakistan, and South Africa.
Barriers to vaccination
High price of vaccines
Ten years ago, it cost countries less than US $1.50 to buy the main recommended vaccines to protect a child’s life; today, the lowest price for the recommended package is nearly $40. That’s because not only are more vaccines now included in immunization programs, but many new vaccines cost much more than older ones.
Getting vaccines to where the children are
Just getting vaccines out to community clinics, and marshalling trained staff to inject them, requires significant costs that poor countries struggle to afford. In conflict zones or natural disasters, when health care systems are disrupted and populations are displaced, children often have nowhere to get routine vaccinations.
Too many clinic visits
The current vaccination schedule requires that children come to a health clinic five separate times during their first year of life. For many families, traveling to a health clinic takes time or money—making it very difficult for them to get complete vaccination coverage for their children, especially when they have many children.
Keeping vaccines cold in hot climates
Nearly all vaccines require refrigeration. Shipping and storing vaccines in a "cold chain" (between 36°F to 46°F) until they are used is tremendously challenging in most poor settings, and is major reason why many children don’t get all the shots they need.
Kids fall through the cracks
Children who miss out on getting vaccinated according to the set schedule are often excluded from free national vaccine programs when they get older, based on their age. In areas of ongoing conflict—like Syria, Chad, Somalia and Central African Republic—entire generations of children can miss out on vaccinations.
Whether vaccinating children in refugee camps against measles, or vulnerable people during urban cholera outbreaks, MSF is increasingly prioritizing vaccination as a core health service. Our strategies center around responding to outbreaks, boosting preventive vaccination in our pediatric and emergency projects, investing in research on ways to better utilize current vaccines, and advocating for cheaper vaccines that are better-adapted to tropical climates and low-resource settings.
Emergency response during outbreaks
Most MSF vaccination activities revolve around emergency responses to outbreaks of vaccine-preventable diseases in settings where children and adults haven’t been covered by routine immunization programs.
In Syria, for example, ongoing war has disrupted vaccinations and other medical services in many parts of the country. Following a 2015 measles outbreak in northern Syria, a coverage survey undertaken by MSF in the Kobane region showed that only 17% of children in families displaced by fighting were fully vaccinated. MSF then supported a nine-day measles vaccination campaign, providing vaccination and vitamin A for children between six months and five years of age. In 2016 we continued supporting both measles campaigns and routine childhood vaccination. For example, in the camps and villages around Atmeh, MSF administered over 118,000 vaccine doses to children under the age of five.
A key aspect of vaccination is logistics—delivering large quantities of vaccine that often require refrigeration across great distances in hard-to-reach areas of low-resource settings without electricity. In 2016 in the Central African Republic, MSF launched a mass multi-antigen vaccination campaign. MSF logistics teams used motorbikes and trucks to transport multiple essential childhood vaccines in coolers to regions all over the country, many without drivable roads. Each morning during the campaign, 370 logistics and medical staff members grouped into 17 team that traveled for hours, fully equipped with all necessary supplies to bring children in the most inaccessible areas up-to-date with their vaccines. In total, more than one million vaccine doses were administered to children under five years old, with vaccination coverage following the first round above 80%.
Introducing new vaccines to impoverished populations
One of the most challenging aspects of MSF’s vaccine initiatives is to bring newer vaccines into the difficult settings where we work. A key hurdle is that these vaccines often significantly increase the cost of the basic vaccination package all children should receive.
A prime example is the vaccine that protects against pneumonia, the leading global cause of childhood death in many developing countries--especially in crowded refugee situations where infections spread quickly. This very expensive vaccine is difficult for many countries, and for MSF, to access at an affordable price. In response, MSF launched the campaign “A Fair Shot,” which helped bring about a drop in the price from as much as $75 to $3.05 per dose for MSF vaccination campaigns during humanitarian emergencies. Since then, a new Humanitarian Mechanism—which we launched together with the World Health Organization, UNICEF and Save the Children—allows all humanitarian actors (but not governments) to access the pneumonia vaccine at the lowest global price during emergencies. Still, prices for routine immunization put the life-saving pneumonia vaccine out of reach in many settings.
Outbreak prevention for all ages
Some life-saving vaccines are essential for both children and adults during epidemics, as in the case of cholera and yellow fever. When appropriate, our vaccination activities target people of all ages during emergency outbreak response. In 2016, our teams supported the vaccination of close to half a million people of all ages against cholera in Zambia. We also supported the vaccination of over ten million people against yellow fever in the Democratic Republic of Congo.
Boosting basic preventative vaccines in pediatrics and emergency programs
MSF is increasingly adopting a more comprehensive approach to get children started, or caught up, on routine vaccination packages. For example, in Borno State, Nigeria, children suffering from acute malnutrition get childhood vaccinations as a part of their care. In Mali, mobile health teams target underserved children with a strategy combining seasonal malaria chemoprevention, rapid nutritional assessment, and vaccination.
Bringing new tools and approaches to the field
A crucial part of MSF’s response is supporting development of simpler ways to deliver vaccines to children and adults and of better-adapted vaccines. For example, while cholera vaccine is usually given as two doses at least two weeks apart, we found that a single dose provides effective short-term protection—which means that very limited vaccine supplies can be stretched further to protect more people during an outbreak.
In another example, in 2014-2015 we tested a new vaccine against rotavirus, a major childhood killer in many low-resource settings. While the standard vaccine is expensive and needs to be kept cold, the new one is cheaper, taken orally rather than injected, and does not need refrigeration. Our trial in NIger showed that the new vaccine was effective in reducing serious illness and death from diarrheal disease. This should make it much easier to reach communities in remote areas with limited access to health services.
Research and development of vaccines adapted for use in developing countries is crucial to increasing coverage. Three of the most important needs are: vaccines with improved heat stability (so they remain stable outside the cold chain for limited time periods), vaccines that eliminate or reduce the need for trained health workers to do injections (for example, through simpler, more flexible routine vaccination schedules), and single-dose vaccinations that don’t require multiple clinic visits or rounds of vaccination campaigns.
Also, expanding the age range during which children can receive free vaccines through national immunization programs will allow those who missed their scheduled childhood vaccines to “catch up” and gain protection against potentially fatal diseases.
Finally, vaccines need to be affordable for all countries, yet the cost of basic vaccination packages is rising very fast—due especially to the more expensive newer vaccines. As of 2014, the cost to fully immunize a child against 12 diseases (based on rates available to UNICEF for the poorest countries) was 68 times more than the cost of immunizing against 6 diseases in 2001.