DiscussionThe value of vaccination: a global perspective
Introduction
Let us assume that we agree that vaccination is one of the most significant public health interventions in the past century, sparing millions of people from infectious diseases. How do we explain that each year when 130 million children are born, about 30 million of these children have no access to vaccinations? Since the establishment of the Expanded Programmed on Immunisation (EPI) by the World Health Assembly in 1974, much progress has been made to bring vaccination into the global limelight but a big gap remains. This study combines economic studies of specific vaccines together to show the broader impact of vaccination as a strategy for better health and economic development. The purpose is to help those making resource allocation decisions have a more accurate picture of return on investing in vaccination.
World-wide, immunisation programs have had a tremendous impact on the prevalence of many life-threatening diseases. Each year vaccines prevent up to three million deaths and 750,000 children are saved from disability [1]. The major success stories: eradication of smallpox, elimination of wild poliovirus from the western hemisphere and most of the eastern hemisphere, the elimination of Haemophilus influenzae type b (Hib) within a few years of introduction of conjugate Hib vaccines in USA, Canada, UK, Scandinavia, France, Germany, Chile, etc. and control of measles in North America—are the tip of the iceberg in terms of the impact of vaccines on our society. Not only have the achievements of vaccination prevented much suffering world-wide, vaccination is a more cost-effective health investment available to healthcare providers than most commonly paid for treatments. The eradication of smallpox alone has resulted in global savings of over US$ 2 billion each year.
While most agree that vaccination is one of the most accepted and cost-effective public health practices world-wide, vaccines continue to be under-used and under-valued, and vaccine-preventable diseases remain a threat to world health. That is to say that, assuming governments and insurers intend to allocate resources efficiently and to use these resources to improve the lives of the people they are accountable to, vaccination should have been disseminated to the point that additional resources would be more effectively spent elsewhere. If payers see only a part of the benefits of vaccination and all of the costs, they are likely to under-invest in vaccination. If doctors do not see the cases prevented of vaccine-preventable disease but do experience the time and effort to provide and monitor vaccination programs, they will not emphasis the importance in their practice. If parents don’t see children with polio and diphtheria; if they read articles about the dangers of vaccination; and have to take the initiative to bring their healthy children into a clinic for vaccination, they are not as likely to be compliant as if they fully understood the value that vaccination provides. Perhaps one reason there remains this gap is that decision-making on logistic and budgetary issues generally is made on a limited vaccine-by-vaccine basis. There has been less attention to the importance and value of vaccination as a health care strategy. As vaccination is more than vaccines, it implies a process of delivery and monitoring. This process is seldom considered including all vaccine series and over the lifetimes of the individuals.
In hopes of more clearly identifying the overall value of vaccination, this paper reviews the global value of vaccination for those making resource allocation decisions, the effectiveness of vaccination initiatives, and the steps necessary to sustain progress and overcome the effects of under-valuation of vaccination on a global scale.
Section snippets
Methods
Estimates of vaccine-preventable cases world-wide, vaccine coverage levels, disease incidence, vaccine costs and cost-effectiveness were obtained through in a four-stage process. First, an electronic document search using Medline, PubMed, the National Library of Medicine, HEED, HSTAT, the Scientific Citation Index, and disease websites, was conducted to obtain online references and statistics from public agencies and academic centres in the United States (Centres for Disease Control, GAVI,
Under-valuation and under-utilisation of vaccines
Prevention is ultimately the most efficient and humane means toward improved world health. Today we have at least 26 diseases that can be prevented or the incidence lowered by vaccination [4]. Yet vaccines are not being used to their full potential [5], [6].
Using EPI program data (DTP, OPV, measles, and BCG series) as a proxy, world-wide average vaccination coverage of children under the age of five fell from 80% in 1990 to 74% in 1999 [7]. One in four children in the world remains without
The beneficiaries of vaccination—individuals, communities and nations
Vaccination is a collective activity in the sense that the act of immunising one person can, for some diseases, lead to the protection of people they would come in contact with. As recently seen with the SARS outbreak, infectious diseases can cross boundaries between countries and continents resulting in a global impact. High vaccination rates benefit all as the spread of infection declines [14]. High rates in one generation can benefit the next generation where disease eradication is achieved
Vaccine effectiveness
The effectiveness of vaccination has been demonstrated in industrialised countries where, following routine vaccinations, several infectious diseases have been controlled and in some cases, eradicated. As shown in Table 1 for the United States, vaccination coverage for the vaccine-preventable childhood diseases has been high for the older vaccines such as DTP, polio, and MMR and increasing for the newer vaccines such as Hep B (going from 68% in 1995 to 88.1% in 1999) and varicella (starting at
Ancillary benefits of vaccination
Vaccination not only provides disease specific benefits to individuals but also ancillary benefits that are often difficult to assess monetarily. The vaccination activities can establish a basis for other health care activities where these are lacking [5], [38], [39]. It provides an opportunity to focus on prevention of disease [40]. In areas with malnutrition, the programs can be opportunities for Vitamin A supplementation [38], [41], [42], [43]. There can be social benefits such as reduced
Economic burden of vaccine preventable diseases and vaccine cost-effectiveness
If a disease cannot be controlled by other cost-effective means, or if control is not feasible, the importance of developing a vaccine against the disease increases. For example, incidence of rotavirus diarrhoea is similar world-wide even in developed nations that have adequate sewage disposal systems, clean water supplies, and adequate housing. In choosing control strategies the added value of immunisation is compared to treatment after infection. While chemotherapeutic agents are currently
Strategies to address the under-valuation of vaccination
From 1985 to 1990 significant progress was made in improving global vaccination programs. However, immunisation rates and infrastructure have since deteriorated and new vaccines have not been available to the developing countries [48], [49]. Current international incentives for new vaccine utilisation are inadequate and imbalanced. A rich child in a rich country receives a new vaccine 10–15 years before a poor child in a poor country receives the same vaccine. In order to accelerate the
Strategies to address the under-utilisation of vaccines
There are additional ways to increase vaccination besides better resource allocation. One could reduce the number of immunisation visits and improve delivery technology. The reduction of wastage by better managing expiration dates; streamlined logistics for storage and supply; and reducing the number of injections needed would all lead to better coverage. Reduced dosing has been successful with the Hib conjugate vaccine. Combination vaccines reduce non-compliance and costs [51]. A number of
Conclusion
Vaccines are unquestionably one of the most cost-effective public health measures available, yet they are under-valued and under-utilised throughout the world. It is important for international agencies, governments, and health policy makers to keep this preventive measure in the spotlight. It is important to remind parents, the general population, and health care providers world-wide to take advantage of this life-saving measure so that no one will suffer diseases that can so easily be
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