Making Vaccines Accessible to All: A Conversation With UNICEF

The COVID-19 global pandemic has cast a spotlight on some of the key issues in ensuring vaccines are accessible for populations in different parts of the world.

The United Nationals Children's Fund (UNICEF) works to protect the rights and save the lives of children across the globe. Part of its mission is to ensure that children in different parts of the world are able to access healthcare facilities, medicines and vaccines.

Immunization is a critical healthcare tool for protecting against life-threatening diseases, as emphasized by the COVID-19 global pandemic vaccination efforts. However, the pandemic has also cast a spotlight on the challenges faced when working to achieve vaccine equality.

UNICEF has supported the delivery of immunization services since 1974 and launched its Vaccines for All campaign – which aims to reach every community, everywhere with life-saving vaccines – in 2020.

Technology Networks had the pleasure of speaking with Dr. Ahmadu Yakubu, senior adviser in health, UNICEF Programme Division, to learn more about the campaign's mission. Dr. Yakubu also discussed the factors that contribute to low immunization rates, how we can work to make vaccines available to marginalized communities and the consequences of vaccine inequality.

Molly Campbell (MC): Please can you talk to us about UNICEF’s Vaccines for All campaign. When did the campaign start, and what are its key aims?

Ahmadu Yakubu (AY): UNICEF's Vaccines for All campaign started in 2020, with the aim of reaching every community, everywhere with life-saving vaccines. It is driven by UNICEF’s equity focus and belief that no child should die from vaccine-preventable diseases. The COVID-19 pandemic re-emphasizes the need to campaign for more children all over the world to get vaccinated with all vaccines in their national schedules. Due to the pandemic, the number of unvaccinated children has increased by 3.7 million between 2019 and 2020, rising to 23 million unvaccinated children in 2020. Despite the challenges, UNICEF’s efforts to reach these children will be sustained.

UNICEF’s Vaccines for All campaign aims to raise awareness of the importance of immunization in saving lives and protecting public health and to highlight the need to continue to reach children with vaccines during the COVID-19 pandemic. It also advocates for governments, donors, partners, communities and caregivers to prioritize immunization and to mobilize resources to ensure all children are reached.

Vaccines protect children from disabling and deadly diseases, enabling them to survive and thrive. They also contribute to healthier communities by shielding populations from infectious diseases.

UNICEF has been supporting the delivery of immunization services since 1974 when the Expanded Programme on Immunization was established. Six diseases (tuberculosis, diphtheria, tetanus, pertussis, polio and measles) were targeted with vaccines at the time. Since then, the package of vaccines delivered by the Programme has gradually expanded, incorporating vaccines such as hepatitis B and haemophilus influenzae type b. Current immunization recommendations include a schedule of 13 vaccines (+ hepatitis B, haemophilus influenzae type b, pneumococcal, rotavirus, rubella, mumps and HPV) for all countries, with additional antigens for specific regions and for some high-risk populations. UNICEF supplies over two billion doses of vaccines each year for both routine immunization and campaigns.

The most common mode of delivery of vaccines is through routine immunization, where countries have schedules for the delivery of vaccines through fixed sites, outreach sessions and mobile teams. These vaccines are forecasted for each year, and UNICEF supplies the vaccines for over 100 countries. On the other hand, vaccination campaigns are undertaken when there is the need for mass delivery of a vaccine to a large target population, usually within few days. To ensure success in terms of reaching the target population, vaccination campaigns are preceded by planning and to ensure the logistics, supplies, communication, advocacy and other activities receive the resources and attention they need. Such vaccination campaigns can be preventive, when they are conducted to avert a likely outbreak of vaccine preventable diseases, or reactive when conducted in response to an outbreak that has already started.

MC: What factors contribute to low immunization rates?

AY: Different factors contribute to low immunization coverage rates across different landscapes. Broadly these factors can be divided into:

A.      Supply factors – making vaccines available, accessible and affordable to the communities in an equitable manner

B.      Demand factors – making vaccines acceptable so that the targeted population or caregivers create demand for the vaccines and seek to access and utilize them

Challenges with availability of immunization services/supply factors

A lack of access or limited access to immunization services is one of the main causes of low immunization coverage. Children may have limited or no access to vaccines due to remoteness, the impact of conflicts, or because they are part of vulnerable population groups, such as children living on the streets or in urban slums. Other issues can include a lack of special outreach to remote or vulnerable populations, the closure of clinics or immunization services due to a lack of staff or limited resources, and the impact of other cross-cutting issues such as gender, for example.

Communities might also experience shortages or stockouts of vaccines or the accompanying injection devices due to their specialized nature. For example, a shortage of syringes or limited cold chain infrastructure could hamper the availability of vaccines. Where these immunization supply chain challenges occur, they can significantly impact on immunization coverage.

Primary health care (PHC) service delivery systems also need to be robust. Most immunization programs in low and middle-income countries face challenges with financing for immunization and PHC services, especially long-term financing.  

Challenges with demand for vaccination

Challenges with demand for vaccination can include limited awareness of the benefit of vaccines in some communities. Combined with low literacy rates, gender barriers or socio-cultural beliefs, it can result in low or non-prioritization of vaccinations in some communities.

Vaccine hesitancy can lead to delay in the acceptance, or refusal, of vaccines despite availability and is of growing concern in some areas, especially in sections of the population that have access to information on social media that may be unsubstantiated by experts.

Financial barriers, other resource constraints including transport fares or payments for clinic charges, or inadequate community engagement are other constraints that could prevent caregivers and parents from seeking care for their children.

MC: What are the key challenges that exist when making vaccines accessible to marginalized individuals?

AY: Immunization programs have been successful in reaching around 83% of children worldwide, but the remaining populations require further resources and accelerated efforts. UNICEF and partners have identified four priorities to access most of the remaining unvaccinated children:

• Urban poor areas
  
  
• Remote/rural areas
  
  
• Children affected by conflict
  
  
• Gender-related inequities and barriers

We are particularly focused on "zero-dose children" who have not received any of the vaccines required for their age and are often deprived of other public health services. In 2020 alone, there were 17.1 million zero-dose children who did not receive a single dose of diphtheria, tetanus and pertussis (DTP)-containing vaccine (this is used as a proxy for zero-dose).

A growing share of children live in middle-income countries where vulnerability and social exclusion, particularly among the urban poor, prevent them from receiving vaccinations. Children living in remote areas, although long identified as a target population for immunization programs, continue to be underserved. Populations affected by humanitarian conflicts also have barriers in accessing vaccines and immunization supplies, including storing vaccines at the appropriate temperatures, quality immunization services, uninterrupted service delivery and the development of immunization registries to ensure continuity of services.

Furthermore, immunization programs often ignore inequities caused by bias and discrimination in response to the social constructs of ethnicity and gender. Gender implications on immunization is not restricted to comparing coverage outcomes between boys and girls, maternal education and maternal age are also key determinants of whether a child is immunized or not. The agency and empowerment of women, and women’s access to quality services, can affect the likelihood of childhood immunization.

Developing better approaches for children who may be accessible geographically, but who remain underserved is also a challenge. Incorporating the latest thinking around effective behaviour change approaches into programs and communication strategies would increase caregiver knowledge about vaccines and vaccine-preventable diseases, improve acceptance and uptake, and strengthening trust within communities.

Reaching these children will also require strengthening primary health care systems, improving the quality of care, greater intersectoral and intragovernmental collaboration, better allocation of resources and a new emphasis on social justice, non-discrimination, civil society engagement and accountability.

The COVID-19 pandemic introduced additional unforeseen obstacles in reaching unvaccinated children in the past 18 months. The social and economic disruptions caused by the pandemic are anticipated to have a dramatic impact on widening inequities and the marginalization of communities and populations globally, further challenging global vaccination efforts.

MC: In your opinion, how has the COVID-19 pandemic highlighted the issue of vaccine inequality

AY: The COVID-19 pandemic has both exasperated this problem and brought it front of mind. But to be clear, vaccines have always been inequitably distributed in some communities.

Even before the pandemic disrupted global immunization services, progress towards reaching the most vulnerable children with vaccines was stagnating. This has continued to be exacerbated by the pandemic, resulting in millions more children going unimmunized, as previously stated.

The latest data shows an alarming increase in the number of children who did not receive any vaccines at all – zero-dose children – putting the fates of millions of young lives in the balance. Most of these children live in communities affected by conflict, under-served remote places, informal or slum settings where they experience multiple deprivations including poor access to basic health and key social services.

South Asia, for example, reported a significant increase in the number of children who did not receive a single vaccine – an increase of 2.1 million children in 2020 compared to 2019, followed by East Asia and the Pacific region (477,000) and Eastern and Southern Africa region, (422,000).

Before COVID-19, global childhood vaccination rates against diphtheria, tetanus, pertussis, measles and polio had stalled for several years at around 86%, well below the 95% recommended by WHO to protect against measles, often the first disease to resurge when children are not reached with vaccines, and insufficient to stop other vaccine-preventable diseases. These gaps have now widened, with many health facilities, resources and personnel diverted to support the COVID-19 response. In some countries, clinics have been closed or hours reduced, while people may have been reluctant to seek healthcare because of fear of transmission.

And of course, most visibly, the global picture of access to COVID-19 vaccines remains fairly bleak. Almost 90% of high-income countries have now reached a 10% coverage target, and more than 70% have reached the 40% target. As of the beginning of September, not a single low-income country had reached either target. This is largely due to the inequity of vaccine availability. In the critical months during which COVAX was created about a year ago, much of the early global supply was bought by wealthy nations. Today, COVAX’s ability to protect the most vulnerable people in the world continues to be hampered by export bans, the prioritisation of bilateral deals by manufacturers and countries, ongoing challenges in scaling up production by some key producers, and delays in filing for regulatory approval.

MC: What are the potential consequences of vaccine inequality, particularly in the context of COVID-19?

AY: The COVID-19 pandemic is far from over. We have seen outbreaks all over the world and the emergence of new and stubborn variants of the virus. This should raise alarm bells for us all. Cases are continuing and health systems are struggling. The cost for children and families has been incalculable, especially in countries with low vaccination rates. The longer the virus continues to spread unchecked, the higher the risk of more deadly or contagious variants emerging — variants that could continue to spread around the world and potentially evade the vaccines we have. 

Moreover, the longer the world struggles to contain the virus, the longer the disruptions to healthcare service delivery around the world will continue, and the greater the risk of other vaccine preventable diseases to cost lives. Helping to immunize the world against COVID is not just morally right, it is an epidemiological necessity. 

MC: What initiatives are UNICEF undertaking to work to overcome vaccine inequality? How can the global population help?

AY: As countries work to recover lost ground due to COVID-19 related disruptions, UNICEF, WHO and partners like Gavi, the Vaccine Alliance are supporting efforts to strengthen immunization systems by:

1)      Restoring services so countries can safely deliver routine immunization programs during the COVID-19 pandemic;

2)      Helping health workers communicate actively with caregivers to explain the importance of vaccinations;

3)      Rectifying coverage and immunity gaps, including identifying communities and people who have been missed during the pandemic; and

4)      Implementing country plans to prevent and respond to outbreaks of vaccine-preventable diseases, and strengthen immunization systems as part of COVID-19 recovery efforts.

The agencies are working with countries and partners to deliver the ambitious targets of the global Immunization Agenda 2030, which aims to achieve 90% coverage for essential childhood vaccines; halve the number of children who completely miss out on vaccination, and introduce more under-used and lifesaving vaccines (such as rotavirus or pneumococcus) in low & middle-income countries.

Governments, the global health community and partners must invest in urgent recovery of essential immunization and other child health services. We have the tools to control diseases that threaten children, but we must now jointly redouble efforts to deploy them equitably and to boost confidence in them. As governments respond to and recover from the impacts of the pandemic, they must prioritize action to strengthen health systems in the poorest countries by increasing global and national investment to continue delivering vaccinations and other critical services for the most vulnerable children.

The global health community must leverage the current political commitment in advancing the delivery of COVID-19 vaccines to push governments to invest more in ALL of the health services that people need, including child routine immunization. Partners, governments and health care workers must work together to build confidence in vaccines – both COVID-19 and the routine immunizations that saves children’s lives. If we are to eradicate preventable disease, we must not falter in our commitment to reach all children with vaccines.

Dr. Ahmadu Yakubu was speaking to Molly Campbell, Science Writer for Technology Networks.