In 2010, in a demonstration of global commitment to immunization, partners from all over the world came together to begin the Decade of Vaccines (2010–2020). In 2011, more than 100 vaccine and public health experts developed the first version of the Global Vaccine Action Plan (GVAP). The plan was refined through a global consultation effort, which included input from more than a thousand individuals representing such fields as government, research, civil society, non-governmental organizations, and manufacturers.
Later, in 2012, the GVAP was endorsed by the 194 Member States of the World Health Assembly to achieve the Decade of Vaccines vision by delivering universal access to immunization. Indeed, the Decade of Vaccines vision is to extend the full benefits of immunization to all people, regardless of where they are born, who they are or where they live.
The plan has four related goals:
- Strengthen existing routine immunization programs to meet vaccination targets
- Accelerate control of vaccine-preventable diseases, with the specific aim of polio eradication as a first milestone to achieve
- Introduce new and improved vaccines
- Spur research and development of next-generation vaccines and vaccine technology
Examples of recent advances and successes made to increase global prevention of death and disease through safe and effective vaccination are listed below:
- A strengthened commitment to global polio eradication.
- Continued strong support and engagement in global disease surveillance and immunization efforts, including measles elimination and expanded use of high impact vaccines including pneumococcal and rotavirus.
- Development and use of new vaccines tailored for global populations, such as MenAfriVac®.
- Greater and more widespread use of influenza vaccines, and development of influenza manufacturing capacity.
- Improved global pandemic preparedness by increasing vaccine manufacturing capacity in developing and under-resourced countries by over 280 million doses through infrastructure-building and technical training to the workforce to ensure high quality vaccine production.
- A continued commitment to reducing the global threat of influenza by building and strengthening capacity for developing and under-resourced countries to produce seasonal and pandemic influenza vaccine.
However, according to Médecins Sans Frontières (MSF), “The Decade of Vaccines is an important plan to protect children against killer diseases, but it lacks ambition when it comes to bringing vaccine prices down and making vaccines better adapted for use in developing countries. The $57 billion Global Vaccine Action Plan does not contain any mechanism to track vaccine prices, despite the alarming fact that the cost to fully vaccinate a child has skyrocketed by 2,700% over the last decade (from $1.38 to $38.80). Just two new vaccines—for pneumococcal disease and rotavirus—make up three quarters of what it costs to vaccinate a child today, yet very little is being done to make sure these prices come down further. Developing countries that will over time lose donor support to pay for vaccines will be left in a precarious position of not being able to afford the high price to vaccinate their children. The vaccines available today are difficult to get to children in the most remote places, which contributes to the fact that one in five babies born each year (22 million) is not protected against childhood killers. The Decade of Vaccines plan does not do enough to make sure that vaccines are developed that are easier to use in hard-to-reach places, such as vaccines that don’t require refrigeration, don’t need to be delivered by needle or can be given in fewer doses. The Decade of Vaccines plan has a very un-ambitious target of just one new vaccination delivery technology in place by 2020, even though several new products could be available much sooner—for example vaccines that are delivered through patches, air pressure or aerosol masks.”
As MSF stated, although the Global Vaccine Action Plan (GVAP) has some beneficial goals, none of these include lowering vaccine costs or creating vaccines more suitable for dispersal in developing countries. The traditional syringe-delivered vaccine is not an ideal vaccination method in developing countries for a myriad of reasons. Firstly, these vaccines must constantly be refrigerated, leading to the cold chain problem. The cold chain involves the refrigerated transportation of vaccines to rural and remote areas; however, this strategy is extremely difficult and often unreliable. Travelling to very remote areas is already challenging enough without the added burden of having to carry refrigeration devices. Additionally, many developing areas do not have access to ice or refrigerators, therefore these places usually have no way to properly store and preserve vaccines. Another issue with syringe-delivered vaccination methods is needle-phobia. Many people, children especially, have very adverse reactions to the idea of a needle penetrating their skin. This can result in difficulties during vaccination delivery or even avoidance of vaccination altogether. Also problematic with syringe vaccination is the fact that immune cells are not abundant in the muscle where needles deliver vaccines. This causes a less efficient immune response than may be possible with other delivery methods. Given these issues with the traditional syringe vaccine, endeavors are underway to develop new and improved vaccination devices, and the GVAP should include funding some of these efforts in its goals. One promising device in development is the Nanopatch. According to its creator, Vaxxas, the Nanopatch delivery system involves thousands of micro-projections arrayed on a small patch. These micro-projections are coated with the vaccine and penetrate the outer layers of the skin. Upon application, the vaccine material is released into the surrounding tissue and produces an immune response just as effective, if not more effective, as that produced by syringe vaccination. The vaccine formulation used on the Nanopatch is heat stable and requires no refrigeration, therefore eliminating the cold chain problem. The micro-projections on the patch are microscopic which removes the issue of needle phobia. Additionally, the Nanopatch delivers the vaccine to the skin where, compared to muscle, a higher concentration of macrophages and other immune cells reside, consequently increasing the vaccine’s effectiveness and quickening the immune system’s response. While the GVAP’s Decade of Vaccines is a great initiative to decrease the mortality rate of infectious diseases, perhaps its goals could include funding further trials for Nanopatch and other emerging vaccination techniques that could prove extremely beneficial to vaccine distribution in developing countries.
I too believe that the old syringe method for vaccination administration, at least in third world countries proves to be ineffective. While I applaud the efforts of those who signed the Global Vaccine Action Plan, without proper funding, even if vaccines were developed for every major disease a sizable amount of the world’s population would have no access to it. The Nanopatch offers a solution to this problem by not needing refrigeration and only a fraction of the vaccine in order to elicit an adequate immune response. One advantage the syringe has over the Nanopatch, however, is that multiple companies produce syringes which drive down the cost. I hope to see a marketplace for the Nanopatch, which include generics. Technology must always advance. The use of needles to inject medicines have been around since the mid-1800’s and for the most part been unchanged, so as someone who loves technology I would like to see a 21st century vaccination delivery system.
Aside from the reduced effectivity of the old syringe method due to lack of proper transportation to remote areas, there multiple other disadvantages. According to UNICEF, healthcare worked gave approximately 16 million injections per year. Ninety to Ninety-five percent of these injections were for curative purposes and five to ten percent were for vaccinations.One major cause of infections to workers and patients are the inappropriate use of or accidental misuse of syringes during these injections. The estimated number of annual infections globally due to unsafe injections is 21 million cases for Hepatitis B, 2 million cases for Hepatitis C and 250,000 for HIV.
Starting from 2011, Global Vaccine Action Plan (GVAP) has been leading by variety of organizations and as the article stated, Bill & Melinda Gates Foundations is one of them.
According to HHS, prior to introducing “Decade of Vaccine”, Bill & Melinda Gates Foundation reported a study about economically benefits after introduced the vaccines toward world’s poorest seventy-two countries from 2011 to 2020. Based on the study, increased rate of Immunization against vaccine-preventable diseases would save 6.4million children and also cost of treatments would save $6.2 billion.
As MSF mentioned, GVAP must put more efforts on Decade of Vaccine plan and be more ambitious about decreasing the price of vaccines and determine easier way to deliver vaccines to developing countries. However, we must admit the contribution of what GVAP aimed for; to provide full immunization benefits to all people in the world.
1) http://content.healthaffairs.org/content/30/6/1021.short
I agree that GVAP sounds like a very ambitious group. Since the goal is “to extend the full benefits of immunization to all people, regardless of where they are born”, more personal elements should be of importance. In my opinion, price plays a major role in public health. If the vaccine is available, but the price is not affordable, then you did not help. I believe that new methods, such as, vaccine patches could be the future of vaccines because of its lower cost, as we learned previously in class. Also, a patch could help people in remote areas who do not have trained professionals to administer the vaccine to them. I think that researches should focus on vaccines that are simpler to administer, as well as, lower costs in order to have a vaccine that helps a larger group of people.
I would like to give additional information about vaccine patch. It is a known example that is delivered by Intradermal route and Bacille Calmette-Guerin and rabies vaccines can be specifically delivered by its route. Intradermal route is driven by outermost skin layer that are rich in antigen-presenting cells and more efficient vaccine delivery method compare to intramuscular or subcutaneous routes; compensate higher immune response with a small dosage. As you mention, vaccine patch could be beneficial when it comes to the cost and to remote places. But it is a shame that not variety of vaccines can be delivered as vaccine patch. Indeed, GVAP should work more ambitious on making vaccines that can be delivered by the intradermal route.
1)http://www.who.int/immunization/global_vaccine_action_plan/DoV_GVAP_2012_2020/en/
I love to hear efforts aimed at enacting and promoting immunization programs that can be beneficial worldwide. The GVAP displays promising goals that would ultimately bring about proactive defense considering the longevity increments seen throughout history from vaccine developments. Per the commentary of the nanopatch by P. Sherman, I secondly support the notion as a potential source for vaccination that minimizes the drawbacks to the standard syringe-needle method, considering the associated pros as a nice alternative. Undoubtedly, however, the recent and fairly new developments for the nanopatch regard it with unknown results of efficacy and time in terms of research progress. Therefore, it is imperative that appropriate to the blog title, the decade of vaccines is one that continues effort in the next generation of vaccines, both old and new methods that can lead to prevention of death and disease. Personally, the best efforts outlined consider the outreach for manufacturing and improving vaccine capacity, aimed at serving under-resourced countries who suffer from ailments that developed countries do not see as problematic. To note, however, were the numbers for the cost of vaccinating a single child over the last decade, “skyrocketed by 2700% over the last decade…$1.38 to $38.80).” These numbers are surely rounded estimates that probably consider healthcare coverage which reduces these prices. To provide a personal opinion, these prices would be a blessing since I have encountered elevated costs. Nonetheless, to note AJel’s comment on “cost of treatment would save $6.2 billion”, seems proactively beneficial, but at best, these are proposed predictions. The relevance and importance is that one should consider an economic standpoint in terms of production, but serving to help mankind through an immunological reinforcement seems well worth any price.
I somewhat agree with twynn’s assertion that making vaccines more readily available, yet still generally unaffordable does not go very far in making strides that help solve the core of the vaccination problem, which is an overall lack of resources in lesser developed countries. While Decade of Vaccines’ campaign and ultimate goals undoubtedly resonate as noble and optimistic in thought, little forethought has seemed to have gone into the realistic outcomes of its practice. Therefore, one can argue that without an increased and greater attenuated focus on overcoming the overwhelming economical barriers that face immunological efforts targeted towards under-developed countries today, no true progress will be seen in immunization and/or possible eradication of vaccine preventable diseases. As has been previously stated in the above comments, the nanopatch is one recently developed device that has the potential to revolutionize vaccine delivery as we know it today, with a pain-free, cost effective selling point that still does not overshadow the attraction of its proven increase in overall immunogenicity. However, despite the clear benefits seen in the use this device, funding for clinical trial testing has just recently been approved for Vaxxas, the biotechnological engineers of the nanopatch, meaning that actual use and distribution for administration by healthcare workers may still be years down the road.
On the other hand, another alternative to the economical drawbacks of needle and syringe immunization that has already gone through a phase 1 clinical study, and therefore, could possibly be on the market sooner than later, is the Bioneedle . The Bioneedle is a non-hollow, biodegradable mini-projectile made of up a starch based polymer and houses a dried drug or vaccine within its cavity. Consequently, the solid, dry makeup of the vaccine, as compared to the conventional liquid solution administered through a hollow needle, eliminates the normally required cold chain for vaccines and accommodates to countries in which the availability of properly working refrigerators are scarce. Furthermore, administration of the Bioneedle is accomplished through the use of a high pressure chamber which houses the 25 mm needle, and upon release of compressed air, drives the needle through a mini-barrel and into the skin in less than 1 ms. Because the compressed air applicator is held above the skin rather than making full on contact, possible cross-contamination of diseases is prevented, thereby facilitating an easily teachable, and risk-free method of vaccination for both healthcare workers and patients.
To add, the needle phobia that is common amongst individuals who are reluctant to get vaccinated is mostly rooted in the perception of pain associated with needle injection and the understandable desire to not want to withstand it. Although the Bioneedle is still a needle is design, because it’s small in both size and weight and can be administered in less than 1 ms, application is not enough to stimulate an action potential within nociceptors (pain receptors), consequently overcoming the discomfort aspect of immunization. For instance, in the clinical trial study consisting of 18 subjects, all reported no sensation of pain during administration of the Bioneedle and described respective overall tolerance as either “good” or “very good”. In addition, arguably the most important advantage of the Bioneedle is the fact that the required dose for vaccination is nearly 50 times smaller than that of needle and syringes. Although the Bioneedle is too large for intradermal injection like the nanopatch, degradation by interstitial fluid amylases following subcutaneous or intramuscular injection facilitates uptake by macrophages and dendritic cells, eliciting an immune response and subsequent storage of adaptive memory cells comparable to those of needle and syringe administration. For example, antigens for tetanus toxoid, hepatitis B, influenza, and TB have all been formulated in Bioneedles with results showing antibody titers comparable/superior to traditional needle injections.
Overall, one can see that advantageous alternatives to immunization and vaccination are rapidly in development and should not be overlooked when focusing on immunological efforts in under developed areas. Although the Bioneedle is not needle-free all together, it is cost-effective, immunologically efficient, and provides a basis for a method of immunization that is easily teachable and less fearsome in regards to discomfort. Therefore, it would be wise for the individuals working within Decade of Vaccines to give more consideration towards new, economically sound methods of vaccination that are soon to be on the market which would help further their efforts of global and equitable immunization.
I agree that it is going to be tough for developing countries to afford vaccines when they are unable to meet their basic survival needs. There are many countries that are unable to provide vaccines for children, but what they can do is have a routine immunization to reduce child mortality. In some countries the vaccines that were given routinely, for measles and DTP, were beginning to decline within the past five years. Countries in south Asia and Africa are unable to afford proper health care, which prevents them from using new approaches.
I think that in order to build a stable program that involves giving routine immunization, there must be “acceptability, availability, affordability, and accessibility.” MSF has responded to the decade of vaccines by trying to come up with a plan that will protect children from getting severely ill from diseases in developing countries. As developing countries are not financially stable, they can’t afford the new vaccines that are out because the prices rose from $1.38 to $38.80. I think that by the year 2020, there will be a new ways to deliver affordable vaccines through the GAVI alliance program. The GAVI Alliance program will help cover vaccination for children in low-income countries.
A 2,700% rise in a decade is shockingly high; especially considering only an average of 30% of the 2,700% is attributed to average yearly inflation rates. I looked into why vaccines, which are needed by so many, are so expensive and generally I found that it’s attributed to greedy companies who exploit their monopoly on these vaccines. Perhaps the GVAP should revise their goals to also include a section of efforts dedicated to mediating this greed. Of course, I don’t think that is really a realistic goal, but one can dream. In addition to decreasing the price of these vaccines, I completely agree with the previous comments of expanding the utilization of more upgraded ways of administering these vaccines, such as the nanopatch, which eliminates the need for the cold chain. But I question whether implicating the nanopatch will assist in decreasing the cost of vaccines, because who is to say the companies who produce these nanopatch vaccines won’t follow the same corporate greed already exhibited currently? Also, because of such expensive doses, some studies find that the cost-benefit of having certain vaccines is not worth it economically unless the costs of these vaccines decrease. I mean, if it’s difficult for non-developing countries to keep vaccines, then the price of vaccines makes it almost impossible for developing countries!
1. http://www.nytimes.com/2014/07/03/health/Vaccine-Costs-Soaring-Paying-Till-It-Hurts.html
2. http://www.fiercepharma.com/story/why-do-vaccines-cost-so-much-ask-pfizer-about-prevnar-13/2014-07-03
3. http://jama.jamanetwork.com/article.aspx?articleid=187492
I commend GVAP’s determination to making vaccinations more accessible to developing countries and eradicating certain diseases. This determination is already seen with the developing shift from needles to patches and biodegradable needles, as discussed above, for vaccine administration. These vaccines though, are still under clinical trials and will possibly take several months to years before they hit the market. There is a new device, however, called the PharmaJet®, that was approved by the FDA in August 2014. This needle-free device delivers a pain-free, high-pressured jet of vaccine through the skin and intramuscularly in one-tenth of a second. It is currently specialized primarily for the influenza vaccine AFLURIA®. The reusable apparatus that emits the vaccine is called a Stratis and contains disposable cartridges that enclose the vaccine. The main goal of the PharmaJet is to alleviate the issue of needle phobias, cross contamination, and accidental needlestick injuries when administering vaccinations. It is also a lot more cost effective in the sense of disposing cartridges via needlesticks. There is no use for sharps containers, thus eliminating needle injuries. A similar jet vaccine was also tested in Cambodia for polio. The Disposable Syringe Jet Injector (DSJI) is especially useful in developing countries where sanitation and proper training for vaccine administration is not of highest importance. For both of these gadgets, the major side effects were slight pain, tenderness, and redness of the injected area, but compared to needles and the process needed to execute a vaccination, this pain can definitely be overlooked.
I agree an alternative to the traditional way of vaccines is the most advantageous answer to the problems in terms of cost of administration in the GVAP initiative. Pharmajet and the nanopatch seem to be the closest things to replacement of the hypodermic needle, but neither seems to be able to fully replace it. Pharmajet (or disposable syringe jet injectors), depending on the vaccine, can only be applied at certain ages. For example, the use of pharmajet for influenza can only be applied to people between the ages of 18-65, but has been approved for use on infants against the measles, mumps, and rubella (MMR) by the food and drug administration. The nanopatch has been tested in mice having seen success in Human Papilloma virus, influenza as well as a few other viruses, leaving vaccine application using the hypodermic needle left for those not able to receive vaccines by the alternatives. At this time, I do not see a way to effectively accomplish the goals of GVAP without using a combination of these apparatuses (with the hypodermic needle being the last resort) until a complete replacement comes along. We are halfway through the decade of vaccines with a long way to go, which might force them to extend this plan another decade or two in order to fully accomplish their goals without the heavy cost.
1.www.cdc.gov/flu/protect/vaccine/jet-injector.htm
2. Immunogenicity and safety of measles-mumps-rubella vaccine delivered by disposable-syringe jet injector in healthy Brazilian infants: A randomized non-inferiority study. (Pubmed)
3.Potent immunity to low doses of influenza vaccine by probabilistic guided micro-targeted skin delivery in a mouse model. (Pubmed)
The GVAP has done a nice job laying out goals for vaccines over the next decade, but based on the meteoric rise in vaccine costs it seems that the focus is on the goals of the corporations funding this research. Introducing and improving vaccines and their technology seems to be the primary concern as opposed to the goals of strengthening programs to deliver to vaccination targets. Many target individuals live in underdeveloped nations that are unable to transport and deliver vaccines, that is, unless of course, the manufacturers’ definition of target refers only to those who have money. In order to achieve all four of the goals laid out by the GVAP it will take efforts planning for the present and the future. In the present vaccines and cold-chain procedures must be improved and made more efficient in order to lower costs and make them accessible to those in need at this current time. For the future we must continue to develop promising technology and find a way to do so affordably. Like many of the other posters I agree that the nanopatch technology is extremely promising as a more effective way to elicit an immune response in an easy-to-transport format. An additional new vaccination method that has not been mentioned is the inhalant form of vaccines. Many of you have probably become familiar with this recently with the introduction of the FluMist spray administered as the flu vaccine. This administration technique has been used to develop other vaccines, such as a live-attenuated dry measles powder at John Hopkins Bloomberg School of Public Health. Similar to the nanopatch a dry powder form would eliminate the need of a cold chain to transport vaccine especially to underdeveloped areas. Additionally, it also has the potential to elicit a stronger immune response than a syringe as well because it is administered to the lungs, which is an entryway to the body for many pathogens. In order to achieve the goals set in place by the GVAP we must continue to improve our current technology for those at risk presently as well as continue to develop new technology to more efficiently aid those at risk in the future.
It’s great that, through GVAP, people are making a world-wide effort to eradicate and have protection against diseases. As we improve the effectiveness, availability, and the discovery of vaccines, we should encourage countries to translate this action plan to enforced regulation. In order for this to happen, properly educating and marketing the importance of vaccines are needed. In United States, inappropriate media and ignorance caused people to not get vaccinated. In order for GVAP’s goals to be met, we need cooperations with companies to regulate the cost of vaccines to increase the availability. Also, proper funding needs to be established, especially for low-income countries, to continuously provide vaccine for many years to come. We should also promote revival of under-researched vaccines for certain diseases (i.e. tuberculosis).
I agree. It’s unfortunate that some people decide not to vaccinate due to misguided information from the media. I think if the media properly educated and enlightened people about the importance of vaccination there would be more support for research. The more support we have, the more funding we can get for research to produce cheaper and more effective vaccines, especially for third world countries.
GVAP is opening the door for changes in worldwide health through this ten year plan that’s been implemented. I agree that the plan needs to focus on more cost effective solutions to in order to be able to make vaccines more available to a larger population. However, I believe that this is something that will come in due time. Just like any new product that is introduced on a market the costs to develop, manufacture, and market are relatively high in the beginning. Over time these prices fall and we begin to see more people with access to products. These prices fall because as consumers we are educated by the media, our peers, and by the company. This drives the demand and in turn reduces the input prices, which leads to lower prices on the consumer level. Now I think with that same economical philosophy applying it to vaccinations we will over time see a trend of decreases in prices on both the producer and consumers side. In order for this to take place it will take proper education from the companies who produce these vaccinations, media, governments who will regulate the use of vaccinations, and it will take time. Time is the key factor. Everyone would love to see instant gratification, but it is needed. We need the GVAP time to reach the four primary goals which are presented in their plan. It is going to take some trial and error on the development side to find “new and improved vaccines”, and to “spur research and development of next generation vaccines and vaccine technology”. Research takes time to do and to use effectively. I definitely am not a fan of the high cost that it takes to fully vaccinate one child, but I can definitely understand why it may be that. Research, development, and administration can be very costly without enough and the right support. GVAP needs more than just 100 vaccines and public health experts and thousands of who gave input to refine the plan. This is definitely a great start because even from a 100 to more than a thousand shows increase support, concern, and efforts to accomplish these goals. Over time with proper research, education, and successful efforts we will begin to see thousands turn to tens of thousands and hopefully millions and more. We are talking about serving billions of people and we need to understand it will take the efforts of millions eventually to accomplish these goals. As more people, organizations, and countries support the plans and efforts of GVAP will be begin to see these goals redefined and new goals defined, but this will all take time so we need to be patient and find ways that we can begin to help on the micro level and effect/influence the macro level of effort to reach these goals.