In the longstanding fight towards treating and preventing infectious diseases, vaccines are on the forefront of combatting worldwide illness and mortality. First discovered in the late 18th century, vaccines brought forth a new wave of biological preparation in order to confer immunity to diseases that had previously been death sentences and causal factors of widespread mortality (“A brief history,” 2015). A series of successful vaccines, introduced over the course of the twentieth century, nearly eradicated many conditions that soon became classified as Vaccine Preventable Diseases, or VPDs (Centers for Disease Control and Prevention, 2015).

Moreover, the Sustainable Development Goals (SDGs) outlined in the 2015 United Nations (UN) Initiative cite expanding immunization access as one of the 169 targets. Development and further improvements upon the immunization process will not only prevent the death and suffering that infectious diseases cause, but also bolster national priorities; both of economic and educational concern (Chan et. al, p. 777). Numerous non-governmental organizations (NGOs) are in the process of collaborating with the United Nations in order to ensure proper implementation of these immunization mandates, as well as mediation of authorities, supplies, and equivocal population treatment (ICG Secretariat, 2016). Since the establishment of the SDGs, more children are now immunized on a global scale than ever before. That being said, the current vaccination rates still only increased by 1 percent (Chan et al., 2017).

Despite these goals, there are still many challenges that UN member nations face in order to fulfill and provide quality immunization care to their citizens. The implementation of pediatric vaccinations remains ever important, as proper vaccination provision allows populations to flourish, rather than diminishing, as (preventable) mortality rates rise. External factors, such as political regimes, also have a significant effect on the overall efficacy of immunization aid.

Although extremely different in nearly every area of comparison, the nations of Nigeria and the United States serve as two interesting case studies. Their immunization policies, priorities, and challenges vary; yet the stark difference in vaccination efficacy among developing and developed nations make for a rather interesting comparison. In the United States, a growing concern regarding vaccinations is the movement against them, causing the emergence of geographical clusters of viral resistance, especially in children (Lieu et al., 2015). Conversely, a pressing issue within Nigerian health care is the ongoing battle against pediatric mortality through the eradication of all six diseases most likely to kill mass numbers: polio, measles, diphtheria, whooping cough, tuberculosis, and yellow fever (Ophori et al., 2014). Despite these stark differences, the United States and Nigeria do share one thing in common: mistrust of the institutional government.

Analyzing the aforementioned countries, in addition to further discussing the historical institution of immunization, will provide an example that all countries (developing and developed) are in need of international empathy and understanding of each others’ health care systems now, more than ever.

The Origins and History of Immunization

Immunization as a medical practice dates back to early 17th century China when Buddhist monks used snake venom as a mechanism of conferring immunity (“A brief history,” 2015). The person most frequently credited with the development of modern vaccines is Edward Jenner, in the late 18th century. By inoculating people with strains of cowpox, he discovered that they would show characteristics of immunity to a similar virus known as smallpox, a global epidemic at the time.

At the most basic level, vaccines work primarily to eradicate and prevent the future development of viruses within hosts (just as antibiotics do with bacterial strains) by creating an environment unsuitable for the virus to thrive. However, the two are not independent of each other. Viruses, by definition, are non-living particles that require support from a host in order to survive and reproduce. (Some common examples of viruses include the Varicella-Zoster and the Epstein-Barr Viruses, known more commonly as chicken pox and mononucleosis, respectively.) That being said, some immunizations also aid in developing resistance to diseases of bacterial origin. The majority of vaccines attack one aspect of the viral life cycle in order to prevent reproduction. Common vaccinations target substructures of viral and bacterial cells, including mitochondria, plasma membranes, and deoxyribonucleic acid — DNA. These immunizations can be administered in different ways and in varying quantities of doses.

Urban industrialization, globalization, and the progression of 20th-century medicine led to significant improvements in immunization technology. This led to the near (if not total) eradication of conditions such as smallpox, polio, diphtheria (DPT), and pertussis (whooping cough). Most nations have their own councils and governmental agencies to publish annual inoculation guidelines, that also serve as basic requirements for any migrant populations wishing to enter the domain of that country. For example, Switzerland has the Commission Fédérale pour les Vaccinations (CFV) to mediate specialist clusters and educate the general population on immunization issues and mandates (Federal Office of Public Health, 2016). There are also international organizations providing humanitarian aid and resources to under-immunized nations, to be discussed later.

Beyond disseminating preventative treatments for vaccine-preventable diseases (VPDs), high immunization rates greatly benefit nations’ economic and educational development (Centers for Disease Control and Prevention, 2015). Financially, immunization is one of the world’s most cost-effective measures. For every US dollar spent on a vaccination, the return on investment is 44 US dollars (Chan et al., 2017). This statistic is based heavily off of the fact that immunization is a preventative measure for VPDs, as more nations trend towards a predictive, people-centered approach rather than focusing solely on chronic and acute disease treatment. Rates of education are also bound to improve, as vaccinations are becoming mandatory for school enrollment in most nations.

Despite these developments, international challenges to widespread immunization and eradication of VPDs still persist. In addition to inoculation targets running behind schedule, access to vaccines and immunization care is extremely limited in developing countries (Chan et al., 2017). This is especially the case for immunizations that require multiple doses, as it is difficult to maintain the equilibrium between quality (number of doses) and quantity (number of people immunized). Furthermore, political conflict and Public Health Emergencies of International Concern (PHEIC) strain the existing fragility of developing nations’ systems, as is the case with the Ebola Virus Disease (EVD) and Zika Virus (ZIKV) outbreaks.

Case Study: Challenges of Vaccinating the Masses in the United States and Nigeria

Another, less pronounced challenge to maintaining high immunization rates is the growing trend against immunization in the Western hemisphere. This problem exists mainly within more developed countries, including the United States. The main difference between under-immunized children here, and in developing nations where resources are scarce, is that parents are electing not to vaccinate their children. Among the reasons for vaccine refusal, religious exemptions and unexplained consequences are the most commonly cited. What is even more intriguing, is that populations of Americans refusing immunization (either for themselves or on behalf of their children) have the tendency to cluster geographically. According to a study published in the medical journal Pediatrics, these clusters “pose public health risks and barriers to achieving immunization quality benchmarks” (Lieu et al., 2015). The study classified two different types of children: under-immunized and vaccine refusal. An under-immunized child is anyone who had missed at least one vaccine by age 36 months, whereas a vaccine refusal included any individual (or the individual’s guardian) who refused to receive one or more vaccine by the same age.

Early 2015 saw a measles outbreak in Orange County, California, where 111 cases in the county alone had been attributed to origins within the Disney theme parks (McCoy, 2015). In a report from the Centers for Disease Control and Prevention (CDC), the period from 4 January 2015 until 2 April 2015 saw a total number of 159 measles cases reported. Falling under the World Health Organization’s (WHO) list of VPDs, the measles, mumps, and rubella (MMR) routine vaccination would have easily prevented this outbreak (World Health Organization, n.d., p.3). Many of the measles patients in the CDC’s study were found to be either unvaccinated (45 percent) or had unknown vaccination status (38 percent). Additionally, the majority of cases were import-associated, meaning that exposure external to the U.S. occurred at least 7 to 21 days before the onset of measles symptoms (Morbidity and Mortality, 2015). Moreover, exposure to infected (and unvaccinated) children poses a serious health risk for other children interacting with them on a regular basis; such as in the case of a primary school environment. Given these statistics, approximately 5 percent of children in Colorado, Connecticut, Kentucky, Arizona, Washington, and California are not vaccinated, putting these clusters of under-immunized populations above what WHO calls “herd immunity”: the threshold under which enough people are immune to an infectious disease that transmission chains are broken within the population (Morbidity and Mortality, 2015).

The most common parental concern with vaccinating children in the U.S. is the belief that vaccinations cause development of Autism Spectrum Disorders (ASDs) and severe side effects. However, according to the CDC, there is no existing scientific evidence to support these claims. In fact, the CDC developed a Vaccine Adverse Event Reporting System (VAERS) in the event that adverse effects do occur in the time period following an inoculation. Nevertheless, researchers specifically look for high numbers of reports of adverse events (symptoms occurring after vaccination in which the vaccine is not a definitive causal agent) or particular patterns after a new vaccine is distributed, with immediate public notification to follow (Centers for Disease Control and Prevention, 2013).

Across the Atlantic Ocean from the United States, Nigeria is concurrently facing development issues regarding vaccination coverage and is attempting to improve. The International Crisis Group (ICG) was established in 1995 in response to a severe meningitis outbreak in Nigeria. The non-governmental organization is comprised of four main members: Médécins Sans Frontières (MSF), International Committee of the Red Cross and Red Crescent (ICRC), World Health Organization (WHO), and the Joint United Nations Program on HIV/AIDS (UNAIDS). Additionally, they hold extended partnerships with member states and vaccine manufacturers (ICG Secretariat, 2016). Although ICG provides humanitarian aid in response to many different types of crises, its involvement is based on the principles of distribution equity, rapid and timely access to care, and independence of decisions from political or economic influences. Because of these three criteria, the ICG ensures equitable vaccine access and resource availability in Nigeria (ICG Secretariat, 2016).

In addition to receiving assistance from the ICG, Nigeria also receives aid from the WHO, which outlined a plan to target all children ages 6 months to 10 years for measles vaccination within the Borno, Yobe, and Adamawa states. The campaign involves assembling and training roughly 4,000 immunization teams to ensure proper delivery, as well as the maintenance of storage supply within ideal temperature ranges. Consequentially, each child is issued a vaccination card and marker in an effort to avoid double vaccinations. Given the system’s past success, (in the years 2000-2015, vaccination prevented approximately 20.3 million deaths), Nigeria has positive outlooks for the efficacy of their new programming (World Health Organization, 2017). This pioneer system was modeled after Nigeria’s highly successful polio vaccine campaign, in which a rapid response ceased further spread of the virus among the population (World Health Organization, 2017).

Focusing further in on Nigeria’s infrastructure, the Expanded Program on Immunization (EPI) states its mission: “The vision of EPI in Nigeria is to improve the health of Nigerian children by eradicating all the six killer diseases, which are polio, measles, diphtheria, whooping cough, tuberculosis, and yellow fever” (Ophori et al., 2014). The national push to fully immunize children under 12 months is under way through monitoring of performance, quality, and safety of the system via indicators that assess vaccination treatment strategy efficacy. The EPI’s overall goal for Nigeria is to strengthen its existing immunization system and accelerate control of infectious disease (polio, measles, yellow fever).

Unfortunately, one significant challenge is problematic, regarding vaccination policy enforcement in both the U.S. and Nigeria: unrest for their respective political health care institutions. According to a study done by the New England Journal of Medicine, public trust in the leaders of U.S. healthcare has declined immensely over the past fifty years. In a 1966 survey, 73 percent of citizens had confidence in their medical care providers and leaders, but that number has since dropped below 30 percent confidence (“Public Trust,” 2014). Could this lack of trust be to blame for declining vaccination rates? Further expanding on the idea of political unrest, it is easy to predict that unrest for other institutions would shortly ensue: including unrest for health care. The United States, a country that has one of the highest health care budgets yet lowest patient coverage and satisfaction, lacks civic engagement. In Nigeria, the EPI believes that immunization networks crumble due to population misconception of ideas, cultural barriers, and rejection of the system out of distrust or fear (Ophori et al., 2014). This sense of community, diminishing both in Nigeria and in the U.S., facilitates network and trust formation while also encouraging collaboration. The Organization for Economic Cooperation and Development (OECD) defines this type of interpersonal growth as social capital: “Networks together with shared norms, values, and understandings facilitate cooperation within or among groups” (“What is Social,” n.d., p.103). Although the concept of social capital is not mutually exclusive to health policy, it does become a major factor in community development, which is a rudimentary foundation of any stable nation’s infrastructure; be it social or economic. Ultimately, this fosters institutional growth, both in the respects of healthcare, economic growth, and education.

Since the inception of vaccination efforts, the public health community has made a substantial amount of progress regarding disease eradication and preventing further spread of VPDs. When considering all of the efforts put in by the UN, ICG, and other NGOs, the global population is slowly approaching some of the goals set in the 2015 SDGs. It’s evident that global immunization efforts are improving, yet numerous external factors still hinder their advancement.

Given the examples of the United States and Nigeria, it’s easy to see that each nation’s vaccination policy possesses faults. In the U.S., a lack of trust in healthcare leaders lends to increasing numbers of under-vaccinated children. Therefore, the problem of geographically clustered development of VPDs, such as measles, emerges. In Nigeria, unification issues and resource shortages further contribute to a sicker, under-vaccinated population, causing more economic stress on an already sensitive infrastructure. Regardless of development and sphere of influence, each country has its own areas in need of improvement. Solidarity in health care provision begins with strengthened networking and social capital. This type of unity can help close the gap in health care equity while also moving economies forward, as the return on investment of a healthy, immunized population is much greater than that of an unhealthy one. Thus, we can move forward and take closer steps to attaining health for all.

References

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