Taking stock in South Africa as Expanded Programme on Immunization marks 40 years

June 2014

The waiting room at the Meadowlands Zone 3 Clinic in Soweto, South Africa, is full of children brought by their parents for their scheduled vaccinations. Medical staff follow a well-rehearsed routine, registering arrivals, weighing babies as part of pre-immunization checks, and vaccinating the young patients.

Lindiwe Khumalo, clutching a blue vaccination booklet, has brought her 18-month old son Sibusiso (Blessing). Lindiwe remembers being vaccinated as a girl and needing her vaccination record for school entry. Now she is a mother herself, she is clear about the importance of immunization.

Waiting room at the Meadowlands Zone 3 clinic in Soweto

“My other child, who is six, is due to get more tetanus and diphtheria vaccinations soon. It is easy to remember because the date the children need to be brought back is written in the booklet,” says Lindiwe, 26.

Lindiwe and her children’s routine vaccination appointments and those of millions worldwide stem from moves by the World Health Organization in 1974 to launch the Expanded Programme on Immunization (EPI). The aim was to target six vaccine-preventable diseases: polio, diphtheria, tuberculosis, pertussis (whooping cough), measles and tetanus. The EPI used the successful smallpox eradication campaign as a model to reach and vaccinate large numbers of people, even those in remote areas. In 1974, about 5% of the world’s children were protected against these diseases; today 83% are.

More vaccines, more challenges

WHO, which works with partners including UNICEF and the GAVI Alliance to provide technical and financial support for vaccination programmes, estimates that the EPI averts 2.5 million premature deaths a year and protects millions of people from illness and disability.

Following the success of the original programme, many countries now vaccinate against at least 9 or 10 diseases, and also target adolescents, the elderly and the wider adult population, says Dr Thomas Cherian, WHO’s EPI coordinator from 2006 to 2012.

“As new vaccines come along there are mechanisms in place through GAVI and other funding sources to make sure that even the expensive, new vaccines get to people in the poorest countries,” says Dr Cherian. But the issue of how to support middle-income countries neither poor enough to get GAVI support nor rich enough to afford vaccines on their own needs to be addressed, he adds, as do the structural demands of greater coverage and a bigger number of vaccines.

“When you introduce more vaccines, a programme becomes more complex. Health workers need more training, and parents need to take in more information,” Dr Cherian says. “Supply chains, distribution networks and monitoring systems need to be strengthened to make sure health systems can accommodate all the vaccines and achieve the required results.”

Monitoring the impact

Sibusiso – left arm

Health officials also face the challenge of reaching the estimated 22 million children who still do not get the basic EPI vaccines.

To improve the targeting and response of vaccination programmes, more and better data are needed. WHO is developing systems, tools and mechanisms to improve the recording and reporting of diseases and also estimates of vaccination coverage at all administrative levels.

“We need to build on the good surveillance programmes that monitor polio and measles, so policymakers can really see the impact of the vaccination programme, and are therefore willing to invest or continue to fund it. This is so important when health budgets become tighter or external support ends,” Dr Cherian stresses.

Back in Meadowlands, Lindiwe and Sibusiso are called to the consulting room where the nurse deftly gives him two shots – in one arm a combined vaccination against diphtheria, whooping cough, tetanus, Haemophilus influenzae type B (Hib) and polio; in the other a second dose of the measles vaccine. A few tears from Sibusio; vaccination booklet updated; visit over until the next scheduled appointment. Routine and rather remarkable.