The emergence of new pathogens and the re-emergence of old ones has made life course immunization an urgent priority, especially in view of rapidly ageing populations. After the coronavirus pandemic, a life cycle approach to vaccinations for all ages and against all vaccine-preventable diseases has emerged as the main strategy to reduce unnecessary hospitalizations, control infectious disease outbreaks and build herd immunity against common infections.
The Region of the Americas adopted the Expanded Program on Immunization (EPI) in 1974. The long-term commitment to pediatric immunization has made this region a global leader in the elimination and control of vaccine-preventable diseases such as smallpox, polio, rubella, congenital rubella syndrome, measles, and neonatal tetanus. In the 40 years since the creation of the EPI, countries have moved from using six vaccines in their national vaccination schemes to an average of more than 16 vaccines, priming the region to take a life cycle approach to immunization.
The Brazilian health system, known as SUS (Sistema Único de Saúde), cares for approximately 75% of Brazilian citizens. Private health insurance is voluntary, supplementary and covers the rest of the population. As per the World Bank, in 2018, government health expenditure per capita was $610.22 or 3.91 % of GDP, with $1.25 billion spent on immunization in 2017. Brazil’s industrial policy has strongly encouraged local vaccine manufacturing.
Brazil reports one of the highest influenza vaccination rates of older adults (98.2%) and those with chronic conditions (86.3%) in the world. However, a recent study of influenza vaccine coverage among adults found a lower rate: of 73.0%, falling short of the goal of 80% set by the national health authority. The most frequent reasons given for skipping vaccination were beliefs about the lack of efficacy and possible side effects of the vaccine. The coverage of vaccination did not differ by socioeconomic characteristics. Older individuals, never smokers, having two or more chronic diseases, and being registered in the Family Health Program were positively associated with influenza vaccine uptake.
A cross-sectional survey of physicians conducted June-August 2018 focused on the vaccines recommended by the Brazilian Society of Immunization (SBIm) for adults and older adults (years 2017-2018) found that the vaccines prescribed by the highest proportions of physicians were Influenza (>90% of physicians for adults and older adults), hepatitis B (adults: 87%; older adults: 59%) and Yellow Fever (adults: 77.7%; older adults: 58.5%).
The Mexican health system is a mix of three components – employment-based insurance schemes, public assistance services for the uninsured, and private insurers. Approximately 8% of the population has private health insurance. Health care is provided free of charge to approximately 85% of the population. According to the World Bank, in 2018, Out-of-pocket (OOP) expenditures were 42.12% of overall spending. Government expenditures on health were $521.01 per capita, last among all the Organization For Economic Cooperation And Development(OECD) countries in 2018, and total health spending accounted for 5.371% of GDP, last among OECD countries save for Turkey.
Mexico has a Universal Vaccination Program that enjoys international recognition, being public and free and among the broadest scope worldwide, with coverage against 14 preventable diseases. For adults 60 and older, hepatitis B, influenza, PPV, and Tdap – and COVID-19 – are covered by the National Immunization Program(NIP); two additional vaccines, varicella and hepatitis A, are covered only at a subnational level due to budgetary constraints.
Mexico uses a trivalent influenza vaccine. The OECD reports that coverage for those 65 and older was 82.3% in 2014. The Mexican influenza vaccination program does not include a recommendation for adults 50- 59 years unless they have risk factors for complications (diabetes, hypertension, obesity, chronic kidney disease and asthma, among others).
For adults >65 years, PPSV23 is recommended. For children, Mexico has benefited from the inclusion of the 7-valent (PCV7) and 13-valent pneumococcal conjugate vaccines (PCV13) since their inclusion in the National Immunization Program(NIP) in 2006 and 2010, respectively. PCV10 is available in the private market.
As of 2020, Mexico lacked a national plan to address viral hepatitis, presenting “a major obstacle for the development and implementation of actions and procuring funding.” Further, the lack of a plan “has not only failed to establish national policies and strategies in the fight against viral hepatitis but also interfered with resource allocation for studies of Hepatitis B Virus(HBV) and Hepatitis C Virus(HCV) epidemiology, clinical investigation as well as basic and applied scientific research” and likely explains the absence of data on Hepatitis B Virus(HBV) vaccination coverage.
The U.S.A. health system is a mix of public and private, for-profit and nonprofit insurers and health care providers. Private insurance, the dominant form of coverage, is provided primarily by employers. The uninsured constituted 8.6% of the population in 2020.
The World Bank reports that government health expenditures were 16.69% of GDP in 2018, or $10,515.32 per capita. The Centers for Medicare and Medicaid Services (CMS) estimated 2021 health expenditure at $4.217 trillion, 18.2% of GDP, with government public health representing 2% of the total.
People enrolled in the Medicare program receive some immunization coverage. Medicaid provides health coverage to more than 76 million people, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government. Immunization coverage in Medicaid is variable by state. Most state Medicaid agencies cover at least some adult immunizations but may not offer coverage of all ACIP-recommended vaccines.
Experts consider the U.S.A. a disease prevention-focused nation. A total of 14 antigens are targeted for adults ages 19 and older, in a combination of risk- and age-based recommendations. But with such a confusing patchwork of coverage, adult vaccination rates remain far below national targets. Additionally, with the ageing of the U.S.A. population, the public health impact of vaccine-preventable diseases and their complications in adults is likely to grow.
The Vaccines National Strategic Plan: 2021-2025 notes that adult vaccination rates remain low overall and continue to lag well behind those for children. For instance, during the 2019–2020 season, influenza vaccination coverage among adults was only 48%.
The available data from the 2018 National Health Interview Survey show that at least three out of every four adults are missing one or more of four routinely recommended vaccines: influenza, pneumococcal, zoster, and tetanus toxoid-diphtheria (Td) or tetanus toxoid-diphtheria-pertussis (Tdap).
The Argentinian health system consists of three sectors: public, social security, and private. The public health system is financed by taxation and provides the majority of health services free of charge to users. The social security sector (Obras Sociales) is a form of health insurance for those working in the formal sector that is financed by employer or employee contributions.
Argentina spends 9.12% of its annual GDP on health services, an increase over expenditure in 2016 of 7.54% of GDP, and higher than the average in Latin America. Argentina implemented a Universal Health Plan in 2016, since which time expenditure has risen. Because of decentralization, there are inequities in the distribution of funds for the healthcare system. Privor-Dumm et al. describe Argentina as a health security-focused country.
While countries across the globe are reporting an ever-increasing proportion of the population aged 65 or over, the Western Pacific Region in particular, has one of the largest and fastest-growing older populations and hosts over a third of the world’s population aged over 65. With an ever-ageing population, life-course immunization is a priority on the region’s health agenda.
In October 2014, the Western Pacific adopted WHO’s Regional Framework for Implementation of the Global Vaccine Action Plan. The region has made significant progress in the battle against vaccine-preventable diseases (VPDs). The Region has maintained polio-free status, maternal and neonatal tetanus (MNT) elimination has been achieved except in one country, rubella elimination is on track, the control of hepatitis B has accelerated, and the introduction of new vaccines, overall, has been on track. However, there are inequities in routine immunization coverage between and within countries, threatening the achievement of the regional goals.
Till September 2019, nine areas had been verified as having achieved measles elimination, and five countries and areas had been verified as having achieved rubella elimination. Despite measles outbreaks in a number of countries (Vietnam and Philippines), the overall number of reported measles cases dramatically decreased by 2011. The COVID-19 pandemic has further exacerbated these inequities with routine immunizations being disrupted. In some countries, routine immunizations were temporarily suspended or delayed, and school closures saw a drop in school-based immunization activities. The decline in routine immunizations and an impaired surveillance system may lead to the resurgence of vaccine-preventable diseases(VPDs) in this region.
Demand is increasing for new and underutilized vaccines that prevent major causes of diarrhoea, pneumonia, meningitis, and encephalitis, as well as cervical cancer, and with it an increased need to assure vaccine safety, quality and adequate supply chain management.
Adaptable solutions were identified which could be implemented (like non-traditional vaccination venues, virtual engagement, and social media campaigns). Governments and private providers realize the need to act urgently to improve coverage rates and plan for future waves of the pandemic, to avoid a resurgence of vaccine-preventable diseases(VPDs).
Australia has a regionally administered, universal public health insurance program (Medicare) financed through general tax revenue and a government levy.
The National Partnership on Essential Vaccines (NPEV), an agreement between the Commonwealth of Australia and the states and territories, guides the immunization program. The objective of the agreement is “to protect the Australian public from the spread of vaccine-preventable diseases through the cost-effective and efficient delivery of immunization programs” under the National Immunization Program(NIP), which aims to minimize the incidence of vaccine-preventable diseases and Human Papilloma Virus(HPV) in the country.
In 2019, Australia spent 9.91% of GDP on healthcare, a little over $5,000 per capita. Total federal spending on health in 2021-2022 was projected to be $98.3 billion, representing 16.7% of the national government’s total expenditure.
Only a few countries, such as the U.S.A., the United Kingdom, and Australia, have implemented an LCI in line with GVAP and the Immunization Agenda 2030 (IA2030). A “whole-of-life” Australian Immunization Register (AIR) was introduced to replace the Australian Childhood Immunization Register (ACIR) in September 2016. The AIR aims to capture all National Immunization Program(NIP)-funded and most privately purchased vaccines given to people of all ages. For adults, only seasonal influenza, pneumococcal, and zoster vaccines are funded through the National Immunization Program (NIP).
In a 2021 paper titled “Enhancing Adult Vaccination Coverage Rates in Australia,” the National Immunization Coalition flagged the lack of complete data on adult vaccination as a critical issue.
The Immunization Coalition estimates that only 51% of older Australian adults receive all government-funded vaccinations annually, compared to 93% of children and 73% of adolescents.
China achieves near-universal health coverage through the provision of publicly funded basic medical insurance.
In 2018, China spent approximately 6.6% of GDP on health care, which amounts to CNY 5,912 billion (USD 1,665 billion), $501 per capita. 28% was financed by the central and local governments, 44% was financed by publicly funded health insurance, private health insurance, or social health donations, and 28% was paid out-of-pocket.
China has the fastest-growing older adult population of any nation: By 2050, more than one in four people in China (26.3%) will be 65 years or older. In this context, adult immunization is a critical imperative for individual and population health. However, China lacks a national adult immunization program on par with its extensive and free pediatric immunization program.
Pediatric vaccines are made available through the government’s Expanded Program on Immunization (EPI) at no charge for all children up to 14 years of age.
Influenza vaccination is not funded by the central government or included in the National Immunization Program(NIP). The influenza vaccination rate is low and varies across the country.
Japan’s statutory health insurance system provides universal coverage. It is funded primarily by taxes and individual contributions. The World Bank reports that health expenditures were 10.74% of GDP in 2019, or $4,360.47 per capita. Out-of-pocket (OOP) accounted for 12.91% of spending.
Despite a rapidly ageing population, Japan remains an outlier in terms of attitudes to adult vaccination, with surveys showing that just 4.7% of adults in Japan agreed that vaccines were important, 25.1% agreed they were safe, and 9.9% agreed they were effective – despite grappling with a flu epidemic in 2019.
While vaccine uptake for paediatric routine vaccines is close to 100%, the uptake for non-paediatric vaccines remains low. National Immunization Program(NIP) category B vaccination (flu and pneumococcal vaccines for elderly people) is not 100% funded, though, for some populations (those over 65 and those 60-64 with chronic illness), these vaccines are free or have copayment support, depending on the local immunization schedule.
Japan has yet to approve the adult tetanus, diphtheria, and acellular pertussis (Tdap) vaccine, nor has it included the vaccine in its national immunization program (NIP).
In Japan, Influenza coverage is approximately 50%. Experts believe increasing the frequency of physician recommendations might lead to increased vaccination coverage.
Health services are delivered by government facilities under the national and local governments. The budget of the Department Of Health(DOH), which had the lion’s share of the national budget for public health services, has increased from PHP 10 billion in 2005 to PHP 123 billion in 2016. PhilHealth premiums comprised the largest line item at PHP 44 billion (36%). Various disease prevention and control programs comprise 6.5% (at PHP 8 billion) and immunization and vaccines 3.2% (PHP 4 billion).
Many Filipinos suffer from vaccine-preventable diseases such as measles and diphtheria. Despite this, immunization rates in the country have fallen. The National Immunization Program(NIP) is largely limited to basic immunization for children: BCG, HepB, Penta, HPV, MMR, IPV, and Td.
Only three vaccines are recommended for adults: PPSV and influenza to those ≥60 years and Td to all pregnant women.
Adult vaccination in Africa has mostly focused on pregnant women and data on other adult immunizations hardly exist but given that the priority area – pediatric immunization- is struggling, it is safe to assume that the prognosis is grim unless a life course approach to immunization is adopted as a national and regional policy.
While predictions of Africa being hardest hit did not come to pass, the region recorded nearly 12 million COVID-19 cases and 256,525 deaths. Member States in the African Region (Burundi, Cameroon, Central African Republic, Chad, Congo, DRC, São Tomé and Príncipe) have learned invaluable lessons that are helping build resilient systems to secure health in the future.
Special strategies were implemented in the area of routine immunization, with seven countries implementing the “Identify, Reach, Monitor, Measure and Advocate” (IRMMA) framework for reducing the number of “zero-dose” children and missing communities. Significant efforts have also been made by some African countries to introduce new vaccines such as rotavirus, Pneumococcal Conjugate Vaccines (PCVs) and, recently Human papillomavirus (HPV) vaccine into National Immunization Programmes (NIPs). Nine countries (Burundi, Cameroon, Chad, Equatorial Guinea, Gabon, São Tomé and Príncipe, Kenya, Uganda, and Zimbabwe) have recently implemented strategies for reducing the number of under-immunized children.
Despite these efforts, the COVID-19 pandemic led to significant interruptions to immunization campaigns in the majority of countries in the WHO Africa region in 2020. This pause, coupled with related disruptions to routine immunization, led to tens of millions of children not receiving polio vaccines. The region was declared polio-free in 2020 but has been threatened by the detection of wild poliovirus type 1 (WPV1) in Malawi and Mozambique in February and May 2022 respectively.
According to WHO’s annual report routine immunization-focused targets were not fully achieved. In 2021, out of a total target population of 38.4 million in the Region, 33.6 million children received the three doses of DTPCV (diphtheria, tetanus, pertussis-containing vaccine), achieving coverage of 87%. Also, 32.1 million children received the first dose of the measles vaccine, a coverage of 84%, which is below the target of 90% for all antigens. The result is a 2.5% increase in the number of under-immunized children in the region.
The underperformance of national immunization systems in the region is largely because of the shift in focus and resources to rolling out COVID-19 vaccination. Since the pandemic, there has been an increased realization that optimal control of vaccine-preventable diseases (VPDs) requires an extension of immunization to adolescents and adults.
Largely, most adults in Africa remain unvaccinated despite the vaccines being available. Although there are fewer recommended routine vaccines for adults in general compared to children and adolescents, the WHO has a set of recommended vaccines for healthcare workers, who, due to the nature of their jobs, are frequently exposed to Vaccine Preventable Diseases (VPDs).
Nevertheless, immunization policies for adults are lacking in many African countries and more research is needed to understand how to best improve vaccine uptake in older populations.
Strategic investments to strengthen health systems are critical to support robust immunization programs that can deliver vaccines to everyone in Africa, including the elderly, a fast-growing demography.
(Note: The figures and percentages mentioned in the articles are based upon data till the year 2021-2022.)
Copyrights ©️
OBSERVERTIMES GLOBAL NEWSNETWORK PRIVATE LIMITED reserves the rights to all content contained within its official website https://observertimes.in/ Online Magazine/ Publications