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[This article was first published in 2005]

"Fate often takes a hand in these things," says the eminent Australian immunologist, Sir Gus Nossal when describing the way he landed on his professional feet after more than 30 years at a Melbourne research institute. "My biggest bit of good luck was that my retirement coincided more or less with the time Bill Gates was building up his foundation."

As chairman of a group of experts advising the US$ 2 billion Bill and Melinda Gates Child Vaccine Program, Nossal is at the forefront of a renewed campaign to immunize children across the Third World -- a major initiative that came about through a conversation. "One day a person in the WHO secretariat in Geneva said, 'Look, my sister lives in Seattle and I'm going to see her for a holiday, while I'm there is there any point in going to see the Gates Foundation?" Struggling to raise funds for immunization programs within the UN system, Nossal immediately said yes.

Two factors prompted a positive reception with the Microsoft chief and his wife, Melinda, Nossal suggests. The 'tremendous cost-effectiveness of vaccines' but also, the couple's personal circumstances: "the fact they had started parenthood late." But, of course, there is more to this story than fate.

In the early 1990s, many within the global vaccine community were starting to feel that the global immunization push had stalled. Some countries were suffering 'donor fatigue', while others were either unable, or unwilling to lift their immunization rates. Moreover, there was a widely held belief that the 'bottle-neck' reflected an under-utilisation of those drugs already available.

At the Sao Paolo meeting of the Children's Vaccine Initiative (CVI) in 1997, Nossal gave voice to these concerns. Talk of a crisis in the area is no exaggeration. Of the 130 million children born each year, 91 million of them are born in the developing world, according to WHO figures. One third of these newborns will never be immunized. Two years after Nossal spoke at the Sao Paolo conference, the Global Alliance for Vaccines and Immunization (GAVI) was launched. Its objective is to ensure every child in the world is protected against vaccine-preventable diseases, regardless of where they are born. Operating as a financial lever behind the new alliance was the Gates Foundation's Global Fund for Children's Vaccines, which was established with a grant of $US 750 million.

Gus Nossal says this renewed effort is motivated by three objectives. First, to improve the human and physical infrastructure in the developing world, which usually means training health workers giving out the vaccines, but can also include buying new refrigerators to maintain the cold chain. Second, to increase the delivery of the so-called 'workhouse vaccines' that have been long available, but for whatever reason have not managed to penetrate the high Third World death rates from diseases largely wiped out elsewhere.

This is no small aim. Five million lives are saved annually from vaccines for preventable diseases such as whooping cough, diphtheria and measles. And yet forty per cent of African children are still not immunized against measles, despite the disease killing one child across the continent every minute. Of great importance too, Nossal says, is the acceleration of vaccines that are almost ready to be used -- the so-called 'low-hanging fruit' vaccines.

Seventy-four of the world's poorest countries -- countries with a GDP per head of less than $US 1,000 -- have been targeted by the scheme. Within four years, it had reached 70 of them. "Of the 30 percent of the world that wasn't immunized with the standard childhood vaccines, about a third have now been immunized," says Nossal, which equates to 'an extra eight to ten million kids.'

Under the Gates' program, a country receives $US 20 dollars for every extra child immunized, on the proviso that it will only get access to new vaccines when 80 per cent of the nation's population is covered. "The carrot was giving money for extra immunizations," says Nossal while "the stick is you can't get the new vaccines until you get to a reasonable number." Reaching diverse populations in the Third World is often fraught with complications. "In some situations there have been civil war. For example, Nigeria is very unstable and that's been a problem for us."

However, Nossal remains convinced that today's outlook is better than thirty years ago. "You have to take progress in small bits," he says before adding: "We haven't done so well in the prevention of wars, but that's not really the doctor's fault." Despite this very real progress, Nossal writes that lifting global immunization rates remains a 'millennial challenge' especially in an era of shrinking aid funds and expanding need. What is needed, he says, is a re-assessment of where health 'sits' on the international aid agenda. In some cases it is also a matter of shifting government attitudes, especially in developing countries where "the Health Minister is relatively low on the pecking order" and overshadowed by an emphasis on economic development.

The irony is that the two are inextricably intertwined. If polio was to be eradicated by the target date of 2005, there would be an estimated $US 1.5 billion savings on immunization costs alone. Moreover, the Commission on Macroeconomics and Health, headed by US economist Jeffrey Sachs, has found that the implementation of a $US 34 billion health reform program in developing countries would generate a US$ 186 billion saving.

"There would be a 6 to 1 cost benefit ratio, simply because of the better health," Nossal says. "The more capacity kids have to go to school, the less time parents are spending at home looking after their desperately sick child dying of malaria and so on. That's not forgetting the eight million lives saved in the process.”

To get an idea of the enormity of the task, consider the longstanding drive to eradicate polio. "Five or six countries still have endemic polio," says Nossal. "Whether one is actually going to eradicate it as totally as small-pox is still finely balanced." More than three million volunteers are needed to immunise 120 million children on a typical national immunisation day in India. Despite the mass mobilization programs designed to target those people Nossal calls 'hard to reach' (nomads, or children of itinerant workers), ten million children still miss out.

Nevertheless, most of the world is now polio-free. The Americas recorded their last case in Peru more than a decade ago and Asia in 1997. This is in part because of a WHO-Rotary partnership, Nossal says. "Rotary have been absolutely generous -- amazingly generous -- not only with money, but also with volunteers."

And yet sub-Saharan Africa and south Asia remain problems, despite renewed efforts to stamp out the deadly disease. Some African nations call 'Days of Tranquility', or ceasefires, so immunization work can proceed. Misinformation can also get in the way. Gus Nossal recalls a recent scare campaign in the Uttar Pradesh border region in northern India. "The polio deaths had been going down, down, down, then someone started a rumour that the polio vaccine was a plot by the Hindus to give it to all Muslim babies (and kill them).

"This got enough currency for the vaccination program to be seriously impeded there. All of a sudden in 2002, we had a mini-epidemic, about 2000 cases of polio." In response, medical teams entered the territory for a massive 'mop-up' campaign. The teams identified cases and re-immunised children and families -- 'intensely from house to house.' The next year cases fell by a sixth and then the work of immunisation resumed.

Surprisingly perhaps for the immunologist who has written five books and more than 520 scientific articles in the area, Nossal says improving the health of the world's poorest populations depends on an understanding that it is 'not just vaccines.' "What about nutrition," he asks. "We have two to three million children with defective vision because of a lack of vitamin A."

Ever the optimist, Nossal proposes a simple solution. "In some countries it is common to give a dose of vitamin A with the polio vaccine." The vaccine has enough vitamin A for to last the patient another six months. "There has been some progress," Gus Nossal says. "But I'd like to see more."



By Professor Sir Gustav Nossal

The diseases for which immunisation is provides under the Gates program are: diphtheria, whooping cough, tetanus, poliomyelitis, measles, tuberculosis, hepatitis B, Hib meningitis, and yellow fever.

The Gates vaccine program targets the 74 poorest countries in the world – all those countries having a per capita income of less than $US 1,000 per year. Here is the prognosis of each of these diseases without inoculation:

Diphtheria: Case fatality rate c. 10%
Pertussis: ( whooping cough) 1-2%
Measles: 1-2% in 3rd world, much lower in industrialized countries.
Tetanus: High unless diagnosed and treated early: 50 –100% depending on circumstances.
Tuberculosis: Many subclinical cases, pulmonary TB high mortality unless treated— perhaps 20-50%.
Poliomyelitis: Very low mortality but high rate of permanent handicap.
Hepatitis B: No mortality in acute attack but chronic disease possible in say 10% of cases with chance of liver cirrhosis and liver cancer; say 1-2% overall long-term mortality.
Meningitis: About 20% untreated; high incidence of complications including mental retardation.
Yellow fever: About 20% untreated; high incidence of complications including mental retardation.

Factors which increase vulnerability: Poor sanitation, poor housing, poor nutrition, intercurrent infections such as diarrhoeal diseases, all the accoutrements of poverty generally. Simultaneous infection with HIV/AIDS makes everything worse.


The GAVI Alliance


The GAVI Alliance (formerly known as the Global Alliance for Vaccines and Immunisation) is a public-private partnership focused on increasing children's access to vaccines in poor countries. Partners include the GAVI Fund, national governments, UNICEF, WHO, The World Bank, the Bill & Melinda Gates Foundation, the vaccine industry, public health institutions and nongovernmental organizations (NGOs). The GAVI Fund provides resources for the Alliance programs. The Alliance provides a forum for partners to agree upon mutual goals, share strategies, and coordinate efforts. Read about GAVI's added value

The Alliance addresses one of the world’s most glaring injustices: the inability of the poorest countries to provide vaccines for all of their children. Roughly one child in four does not receive any vaccinations. Of the 130 million children born each year, two to three million will die from vaccine-preventable diseases. Read about vaccine-preventable diseases

The belief that all children – no matter where they live – deserve a healthy start is the foundation of GAVI's work. It is unconscionable that existing vaccines – vaccines that save lives and cost little – vaccines that parents in industrialized countries take for granted – do not reach every child, every where. Further, when new vaccines are created, children in poor countries should not be forced to wait a decade or more to benefit.

Childhood immunisation is one of the best values in health care, providing tremendous benefit at very low cost. A child can be immunised for only $30. It is a near-perfect intervention, preventing disease before it is allowed to take root, protecting children when they are most vulnerable and providing them with a healthy start in life. Read about the economic impact of vaccines

The world knows how to immunise its children. It has lacked leadership and resources focused on getting the job done. Now, guided by the GAVI partners' vision, and with the GAVI Fund raising new money for global immunisation, lives are being saved.






Links to a wide variety of organizations involved in immunization delivery, vaccine research, promotion of safe injections, and child survival.

American Academy of Pediatrics

* Visit website

American Medical Association: Pediatric vaccination

* Visit web page

BASICS (Basic Support for Institutionalizing Child Survival)
BASICS, the US government's largest child survival project, works in collaboration with other international agencies, nongovernmental organizations, health systems, and academic institutions and provides technical assistance to public health programs in developing countries. This website offers publications and a bibliography related to sustainability of immunization efforts.

* Visit website

US Centers for Disease Control and Prevention (CDC)
CDC's mission is to promote health and quality of life by preventing and controlling disease, injury, and disability.

* Visit website

* National Immunization Program website

* CDC's viral hepatitis web page

The Communication Initiative: Immunisation, vaccines, and polio
This site contains links to select programs, data, and materials, from various development organizations focused on immunization initiatives.

* Visit website

Every Child By Two
This organization, founded by Former First Lady of the United States Rosalynn Carter and Former First Lady of Arkansas Betty Bumpers, focuses on reducing infant mortality through timely immunization.

* Visit website

Health Information for Development Project (Information Waystations and Staging Posts)
The Health Information for Development project has compiled a Global Directory of Health Information Resource Centers with information about hundreds of international and local organizations providing health information to providers and consumers in the developing world. The full directory is available for download, or you can browse the database.

* Visit website

Immunization Action Coalition
The Immunization Action Coalition (IAC) promotes physician, community, and family awareness of, and responsibility for, appropriate immunization of all children and adults against all vaccine-preventable diseases. This US-based site has a wealth of education materials, including vaccination information sheets in many languages.

* Visit website

IAC's Vaccine information for health professionals web page

Building on the work of earlier projects, including BASICS, Partners for Health Reform Plus, and CHANGE, IMMUNIZATIONbasics continues USAID's longstanding immunization support to host-country governments and other international organizations.

* Visit website

Institute for Vaccine Safety, Johns Hopkins University
A good source for news on vaccine safety issues.

* Visit website

The International Federation of Pharmaceutical Manufacturers Associations (IFPMA)
IFPMA represents the research-based pharmaceutical industry and other manufacturers of prescription medicines worldwide. It is the main channel of communication between this sector of the industry and the World Health Organization, as well as other international organizations that are concerned with health-related issues. This site provides access to IFPMA policy documents on issues such as intellectual property, essential drugs, and quality assurance.

* Visit website

The International Vaccine Institute (IVI)
Based in Korea, IVI is dedicated to improving human health through research, development, and strengthening vaccine science capabilities for developing countries. This website offers IVI publications and reports, as well as an events calendar.

* Visit website

National Alliance for Hispanic Health Immunization Program (Vacunas y Inmunización)
Materials for parents are available in English and Spanish. Hay información sobre las vacunas en español.

* Visit website, English/Español

National Network for Immunization Information (NNii)
NNii promotes public education to sustain and build confidence that immunizations are in the best interests of children, adolescents, and adults. The network is a project of the Infectious Diseases Society of America (IDSA) and the Pediatric Infectious Diseases Society (PIDS) and is designed to serve as a source of comprehensive information on vaccination and vaccination-related issues for parents, health care professionals, and the media.

* Visit website

Pan American Health Organization (PAHO): Immunization
News and resources from the Americas region of the WHO.

* Visit web page

Parents of Kids with Infectious Diseases (PKIDs)
This national parent advocacy organization is committed to protecting American children against diseases that have life-long effects on their health and development.

* Visit website

PATH is an international, nonprofit organization that creates sustainable, culturally relevant solutions, enabling communities worldwide to break longstanding cycles of poor health. By collaborating with diverse public- and private-sector partners, PATH helps provide appropriate health technologies and vital strategies that change the way people think and act. PATH’s work improves global health and well-being.

* Visit website

The Sabin Vaccine Institute
The Sabin Vaccine Institute promotes rapid scientific advances in vaccine development, delivery, and distribution worldwide.

* Visit website

UNICEF: Immunization plus
UNICEF advocates and works for the protection of children's rights, to help the young meet their basic needs, and to expand their opportunities to reach their full potential. Search for keyword "immunization" to find UNICEF statistics and immunization programs.

* Visit web page

US Agency for International Development (USAID): Immunization
USAID is an independent government agency that provides economic development and humanitarian assistance to advance US foreign policy. This web page provides an overview of USAID's role in efforts to immunize the world's children and links to related resources.

* Visit web page

VillageReach is an entrepreneurial, nonprofit organization that assures access to lifesaving immunizations for families in low-income countries with the greatest need.

* Visit website

World Bank
The World Bank offers loans, advice, and an array of customized resources to more than 100 developing countries and countries in transition.

* Visit website

World Health Organization (WHO) Immunization, Vaccines, and Biologicals
The WHO site has a wealth of information on vaccines and immunization.

* Visit web page



[Reuters, February 8, 2007]

The Group of Seven industrialized nations plans to sign an agreement to provide $1.5 billion to develop vaccines for diseases -- including HIV/AIDS, TB and malaria -- that largely affect developing countries, the government of Italy announced on Reuters reports. Under the program, donor countries will pledge to buy vaccines that are being developed at a preferential price when they are available. This would create a financial incentive for drug companies to develop vaccines for diseases that largely affect developing countries, Bloomberg reports. Canada, Italy, Norway and the United Kingdom plan to make funding pledges on Friday.

According to Italian government sources, Italy plans to pledge $500 million; the United Kingdom is expected to pledge $400 million; and Canada and Norway are expected to pledge $200 million each, Reuters reports. Officials from the G7 countries plan to explain the program to Pope Benedict XVI ahead of the G7 meeting in Essen, Germany, according to the Italian economy ministry. (Reuters, 2/6). Leaders of the Group of Eight industrialized nations at their summit in July 2006 did not act on an opportunity to adopt a similar advance market commitment plan aimed at funding the development of vaccines for diseases such as HIV/AIDS, TB and malaria.