What can WHO regions learn from PAHO's immunization program? Three external advisors share their thoughts

Dr. MacDonald, Dr. O'Brien and Dr. Cravioto praised PAHO's strategies to eliminate diseases and listed seven lessons other WHO regions can learn from the Organization.

Let's admit: PAHO is proud of the numerous achievements of its immunization program. It is one of the Organization's best-known areas of work. Member States continuously praise it and pledge their support. But is this appreciation shared by people external to PAHO? Can other WHO regions benefit from PAHO's initiatives and lessons learned, given their different reality?

We asked these and other questions to three members of WHO's Strategic Advisory Group of Experts on immunization* (SAGE) who visited PAHO in February to learn about our immunization program: Dr. Alejandro Cravioto, Dr. Noni MacDonald, and Dr. Kate O'Brien.

Dr. Alejandro Cravioto
Dr. Alejandro Cravioto
Dr. Noni E. MacDonald
Dr. Noni MacDonald
Dr. Katherine O'Brien
Dr. Katherine O'Brien

How does PAHO's immunization program fit into the wider context of WHO regions?

The countries of the Americas have always considered vaccination programs as integral parts of their health systems and not as separate programs added on to the health system. This allows the immunization programs to be more efficient and better financed. PAHO has always had a strong presence and leadership in the Region and has helped to develop better health systems, which include better vaccination programs.

PAHO has a long history, predating WHO and longer than any of the other WHO regions. The impact is that it has many longstanding relationships between and amongst countries around immunization. These traditions of countries working together on immunization programs, sharing lessons learned etc. has built trust in PAHO and amongst the countries.

In contrast to other regions, PAHO has had fewer recent or current mass humanitarian crises that can otherwise impact a country's immunization programs. When these have occurred - many countries in the Region have stepped in to help - e.g. Haiti earthquake.

The needs from small countries in the Region for immunization program support-which has much often bedeviled other WHO regional offices- appears not to be such a problem in PAHO except for those in Haiti.

Acronyms mentioned in this article
AEFI - Adverse events following immunization
Gavi - Global Alliance for Vaccines and Immunizations
NITAGs - National Immunization Technical Advisory Groups
TAG - Technical Advisory Group on Vaccine-preventable Diseases
SAGE - WHO Strategic Advisory Group of Experts on immunization

How would you describe the Expanded Program on Immunization (EPI) in the Americas Region?

PAHO presents an interesting mix of high, middle and a few low-income countries. The EPI programs are well supported by the local governments and there is a flavor of co-operation that pervades the Region. PAHO has a long history of innovation. The longstanding Revolving Fund is an excellent example of how countries working together to purchase vaccines has benefited immunization program development for all, as access to affordable vaccines is a critical element in EPI program success. This is particularly important for small countries that have no leverage for attracting favorable pricing on their own, because their purchasing power would be limited. The transparency of this process is key and is to be commended.

PAHO has developed successful strategies for the eradication/elimination of vaccine-preventable diseases like smallpox, polio and more recently, measles and rubella that have been innovative and used over time to accomplish similar benefits. This spirit of collaboration around immunization meant that polio eradication came much earlier to this Region than to others. The program of routine immunization, mop-up and targeted campaigns and "Days of Tranquility" provided a model for other regions. It comes as no surprise that PAHO was the first region to be declared measles and rubella free.

PAHO has also worked hard to encourage countries to collect quality data on immunization and vaccine-preventable diseases and then show how this kind of information can be used in designing and supporting interventions to improve uptake. The Latin America and Caribbean countries' use of the ProVac tool and strong country NITAGs are examples of how PAHO countries support evidence-based decisions around immunization policies. Notably, PAHO is the only region where several small countries have fully integrated patient-centered health information systems (Belize, St. Lucia, St. Vincent and the Grenadines, Barbados) that simplify disease surveillance and assessment of vaccine uptake at a relatively modest cost.

What lessons do you think PAHO can share with other regions?

  1. Revolving Fund
  2. How to support small countries
  3. Intercountry sharing of programs, lessons learned
  4. Maternal immunization program success and enablers
  5. Efforts to optimize data quality, analysis
  6. Vaccination Week in the Americas
  7. Importance of disease surveillance programs for monitoring immunization program impact

What do you see the as the major policy challenges and opportunities at the global and regional levels moving forward?

To truly control vaccine-preventable diseases - no country and no person can be left behind-this requires global thinking.

As countries graduate from Gavi - many are finding it hard to go forward - how low middle income countries are managing needs to be more explored and lessons learned shared across regions.

Web 2.0 (internet and social media) has changed the information-sharing landscape and raised anti-vaccine sentiments to new audiences - more work is needed to grow and enhance vaccine program resiliency in the face of anti-vaccine rhetoric in different contexts - similarly, best practices on how to reestablish trust need more attention - e.g. Colombia and the HPV vaccine.

More expeditious causality assessments of serious adverse events following immunization (AEFIs) and then better sharing of the findings in a way that can be easily understood could help assuage vaccine safety concerns and grow more trust.

Serious efforts are needed to grow pro-vaccine support and the ability of parents and adults to critically assess information - perhaps also with inoculation against anti-vaccine sentiments.

How could we strengthen linkages between the immunization advisory groups at different levels?

Develop stronger ties between PAHO and the SAGE members from the Americas region - regular visits from the SAGE [members to PAHO (e.g. annually) would benefit both PAHO and SAGE members; SAGE/AMR members could also be offered the opportunity to attend the TAG meetings annually.

Support for more discussion around the enablers and barriers of quality immunization programs - especially around communication, subgroups, vaccine safety and education e.g. perhaps more PAHO country presence/participation at the Global NITAG Network.

Having PAHO gain an understanding of how the SAGE agenda and recommendations are developed would be beneficial; strengthen the link between the TAG topics and new issues arising so these are fed back to the SAGE/AMR members and up to the SAGE Secretariat; evaluating how PAHO countries are or are not able to translate these recommendations at the regional level would benefit all.

(*) Current SAGE members Website

Author: Paulo Lyra, AM/SII, PAHO/WHO
Edition: Octavia Silva, FGL/IM, PAHO/WHO