The Immunization Program in the Americas: a history told through the Immunization Newsletter
Through the years, vaccination has proven to be among the most cost-effective, cost-beneficial, high-impact actions most widely accepted by society for the improvement of the health of its peoples.
In the 1970’s, countries throughout the world faced a high burden of morbidity and mortality brought on by vaccine-preventable diseases for which vaccines already existed, but were not being properly utilized due to a lack of consolidated programs and successful strategies. In 1974, the World Health Assembly called upon countries around to the world to establish an Expanded Program on Immunization (EPI). This global EPI included biologicals against six priority diseases: severe forms of tuberculosis, polio, diphtheria, pertussis (whooping cough), tetanus, and measles. Against this background, in 1977, the Directing Council of the Pan American Health Organization (PAHO) – composed of the Ministers of Health of the countries of the Americas – adopted a Resolution establishing the Expanded Program on Immunization for the Americas. To further strengthen and accelerate the establishment of the EPI in Member States, in 1979, the PAHO Directing Council established the Revolving Fund for vaccine procurement. The prime objective of the Fund was to provide timely and sustainable access to high-quality vaccines, syringes, and cold chain equipment. The EPI Newsletter (now Immunization Newsletter) was born that same year, 1979, as a periodic publication to exchange skills, knowledge, and information relevant to the EPI in the Region of the Americas.
With the implementation of the EPI, vaccination coverage in the Americas increased from rates of 25% to 30% over the early 1970s to coverage rates close 60% by the early 1980s, and to over 90% by the first years of the 21st century. By 1985, the advances made by the immunization programs afforded the countries of the Americas the confidence to embark on the goal of eradicating poliomyelitis from the Western Hemisphere. A goal that was achieved in 1991, as the last wild polio case was reported in Peru that year. In 1994, the International Commission for the Certification of Poliomyelitis Eradication in the Americas concluded that the indigenous circulation of wild poliovirus in the Western Hemisphere had been interrupted. Thanks to this success, the countries of the Americas decided to embark on a new regional initiative: the elimination of measles. The last indigenous measles case in the Americas was reported in 2002. In 2003, thanks to this latest accomplishment, the countries of the Americas once again established a regional challenge: to eliminate rubella and congenital rubella syndrome (CRS) from the Region by 2010. No indigenous rubella cases have been reported since 2009.
Thanks to advances in immunization and public health research, new biologicals have become available and have been added the EPI’s regular vaccination schedules over the first decade of the 2000s. Today, all countries in the Americas vaccinate against rubella, and all but Haiti have also added vaccines against mumps, Hepatitis B, and Haemophilus influenzae type b (Hib). Haiti plans to introduce these vaccines in 2012. Most countries also offer vaccination against seasonal influenza and all enzootic countries include the yellow fever vaccine in their regular vaccination schedules. The uptake of rotavirus and conjugate pneumococcal vaccines in the regular vaccination program of the countries of the Americas has been the quickest in the world. This has allowed for an increase in the number of lives saved, contributing to the achievement of the Millennium Development Goals. Additionally, the increase in the use of the vaccine against Human Papilloma Virus (HPV) by countries in the Region in recent years, once again places the Americas on the vanguard. With the advent of new vaccines and their subsequent introduction into national EPIs, childhood immunization programs have evolved into family immunization programs.
Immunization is one of the most cost-effective interventions available in public health. More than half of the gains in reducing child mortality in Latin America and the Caribbean in recent years are attributable to immunization. Vaccines continue to be one of the key interventions to reach the Millennium Development Goal of reducing child mortality. The success of the immunization programs in the Region is attributable to several factors. These factors include strong political commitment from Member States, because immunization programs are considered a public good in most countries; sound program management; the development and implementation of annual and multi-year immunization plans of action; the existence of legislation facilitating the financial sustainability of immunization programs, securing funds for vaccine purchase and other operations of the immunization program; the use of data for action, through an adequate surveillance system backed by an effective network of diagnostic laboratories; and the ability of the program to adapt and to respond to exceptional circumstances, as they did, for example, during pandemic vaccination in 2009-2010.
As a Regional Immunization Program, the technical support provided by PAHO Secretariat to Member States has been important. Other key factors include: the core value of cooperation among countries or Pan-Americanism; cross-border coordination of vaccination and surveillance activities; the open exchange of information and experiences – in different forums, including the Immunization Newsletter; PAHO’s permanent technical cooperation support for countries in need; the Revolving Fund for vaccine procurement, as a mechanism for equity and solidarity, which guarantees access to high-quality vaccines at reasonable prices; and well-functioning technical oversight and partner coordination. It is worth noting, the important role of PAHO’s Technical Advisory Group on Vaccine-preventable Diseases (TAG). The TAG, which is a regional oversight body of immunization and vaccine experts from the Americas, meets biennially to review progress, set standard goals and targets for improving immunization coverage, and provide recommendations on the strengthening of vaccine-preventable disease surveillance and improving vaccination efforts in the Americas.
Another important regional initiative has been Vaccination Week in the Americas (VWA). Since its inception in 2003, each year, VWA has provided a key opportunity to extend immunization services to the unreached and to keep immunization on the political and social agenda of Member States. Other Regions of the World Health Organization have embarked on similar initiatives and the dream of a World Vaccination Week is now in reach.
ew interventions match the impact that immunization continues to have in transforming the global health landscape. As we enter the second decade of 21st century, PAHO’s Regional Immunization Vision and Strategy (RIVS) serves as a roadmap for immunization programs to: 1) protect the achievements, in terms of vaccine-preventable disease control, elimination, and eradication; 2) address the unfinished immunization agenda, including expanding the use of underutilized vaccines such as influenza and yellow fever, eliminating neonatal tetanus in Haiti, and increasing coverage levels to ≥95% in every district or municipality; and 3) face new challenges, such as introducing new and relatively more expensive vaccines. To this end, PAHO’s ProVac initiative is helping countries to make more informed, evidence-based decisions for new vaccine introduction by providing technical assistance and support on the use of tools for economic evaluations and by supporting National Immunization Technical Advisory Committees.
the Americas. All efforts, made at both the country and regional level, have been captured in the pages of the Immunization Newsletter. This newsletter is not only a document that keeps the history of successes and challenges of the EPI in the Americas; it is also a living tool that can serve as reference and example for other programs and regions. Furthermore, the Immunization Newsletter serves to recognize the arduous daily efforts made by public health care workers to ensure that all children, families and communities are properly vaccinated.
Cuauhtémoc Ruiz Matus
Pan American Health Organization