Make EPI an ‘Essential Programme on Immunisation’ 

1. The Evolution of Immunization Programs

The Expanded Program on Immunization (EPI) was established with the anticipation of eradicating the smallpox virus, leveraging existing immunization infrastructure and training personnel to extend vaccine benefits. Initiated globally, it prompted nearly every country to launch its national immunization program. In 1978, India inaugurated the EPI, later renamed the Universal Immunization Programme (UIP) in 1985. This year marks two decades since the last nationwide independent field evaluation of the UIP in India, presenting an opportune moment for assessment and future envisioning.

Global and Indian Progress in Immunization

Over the decades, significant advancements have been achieved globally and in India in terms of immunization impact and vaccine availability. From having vaccines for six diseases in 1974, the repertoire has expanded to include vaccines against 13 universally recommended diseases, with an additional 17 recommended for specific contexts. Moreover, ongoing research aims to develop vaccines against approximately 125 pathogens, many targeting diseases prevalent in low- and middle-income countries.

2. Successes of Immunization Programs

Increasing Coverage and Disease Prevention

The proportion of children receiving three doses of DPT, serving as a tracer indicator, has seen a remarkable rise since the early 1970s. In low- and middle-income countries, coverage increased from around 5% to 84% globally by 2022. Notably, smallpox has been eradicated, polio eliminated from most countries, and many vaccine-preventable diseases nearly eradicated. In India, coverage has consistently improved, with 76% of children receiving recommended vaccines between 2019-2021.

Saving Lives and Economic Benefits

Studies post-EPI launch demonstrate that vaccines have saved millions of lives and averted billions of hospital visits and hospitalizations. Economic analyses reveal vaccines as highly cost-effective interventions, generating a seven to 11-fold return for every dollar (or rupee) invested in vaccination programs.

Government Program Success and Utilization

In low- and middle-income countries, including India, immunization programs often outshine other government initiatives, boasting higher coverage rates. Even in mixed health systems, where both public and private sectors deliver services, immunization remains predominantly a government-driven intervention. For instance, in India, despite the private sector's dominance in health services, government facilities deliver 85% to 90% of all vaccines. Experts contend that immunization coverage serves as a benchmark for the highest possible coverage attainable by any government intervention.

Challenges and Persisting Inequities

Despite the successes, a concerning trend emerged in early 2023, as UNICEF's 'The State of the World's Children' report revealed a decline in childhood immunization coverage in 2021, marking the first such instance in over a decade. Globally, an estimated 14.3 million children received zero recommended vaccines in 2022, with an additional 6.2 million partially immunized. While vaccination coverage has risen over the years in India, persistent inequities persist based on geography, socioeconomic status, and other parameters, necessitating urgent interventions.

3. Expanding Focus to Include Adults and the Elderly

Historical Perspective on Vaccination

Vaccines have historically been available for individuals of all age groups, with the first vaccines targeting diseases like smallpox, rabies, cholera, and typhoid primarily for adults. Even the BCG vaccine against tuberculosis, introduced in 1951, was administered to adults. This history underscores the fact that vaccines have always been intended for individuals across all age groups.

Shift in Priorities

Children have traditionally been prioritized for vaccination due to their vulnerability to vaccine-preventable diseases. However, with increased vaccine coverage and better protection for children, preventable diseases are now emerging more commonly among adults. Thus, there is a need to shift focus towards vaccinating adults and the elderly.

Policy Recommendations

• The government should consider providing recommended vaccines for a wider section of adults and the elderly, making them available for free at government facilities once recommended by the National Technical Advisory Group on Immunization (NTAGI).
• NTAGI should extend its recommendations to include vaccines for adults and the elderly, as government endorsements significantly impact vaccine coverage.
• Proactive measures must be taken to dispel myths and misconceptions about vaccines, leveraging professional communication agencies and social media platforms to educate the public.
• Professional associations of doctors should collaborate to raise awareness about vaccines among adults and the elderly, utilizing opportunities during patient consultations to promote vaccination.
• Medical colleges and research institutions should conduct studies to assess the burden of diseases among the adult population in India, informing vaccination strategies.
• The introduction of new vaccines for adults and the elderly may enhance coverage of childhood vaccines and reduce vaccine inequities, thereby strengthening existing immunization programs.

Call for Action and Program Expansion

India's EPI has shown significant progress, but it's time for another national-level review, engaging key stakeholders and international experts. Initiatives like adult BCG vaccination pilot programs and the COVID-19 vaccination drive have sensitized the public to the importance of adult vaccination. This presents an opportune moment to expand the immunization program to focus on zero-dose children, address coverage disparities, and offer vaccines to adults and the elderly, making EPI an 'Essential Program on Immunization' for all age groups.

4. India's Achievements in Vaccination

India has a rich history of successful vaccination efforts, with documented practices dating back to the 18th century. This success story continues today, with the country making significant strides in protecting its citizens from preventable diseases. India's triumph over smallpox in 1977 paved the way for further advancements. The Expanded Programme on Immunization (EPI) was Launched in 1978, the EPI introduced essential vaccines like BCG, DPT, and OPV. The latest NHFS data reveals a steady rise in childhood vaccination rates, with 76% of children now fully vaccinated.

Initiatives and Achievements

• India actively contributes to the SDGs by prioritizing immunization for newborns, infants, children, and pregnant women.
• The UIP offers vaccines against 11 national diseases and one sub-national disease.
• The program targets nearly 2.7 crore newborns and 2.9 crore pregnant women annually.

Mass Immunization Campaigns

• Measles-Rubella (MR) Vaccination Drive successfully vaccinated over 3 crore children in three years, significantly reducing measles deaths.
• Mission Indradhanush was Launched in 2014, this mission intensified immunization efforts with catch-up rounds to achieve and maintain 90% full immunization coverage nationwide.
• Pneumococcal Conjugate Vaccine (PCV) is a Made-in-India vaccine, that helps prevent rotaviral diarrhea and pneumococcal pneumonia in children.

• Lockdowns caused disruptions in routine immunization services and health facility closures.
• Despite rapid vaccine development during the pandemic, an "infodemic" fueled vaccine hesitancy among some populations.

• India's investments in research & development and manufacturing capabilities have yielded significant results.
• The development of Rotavirus, PCV, and two COVID-19 vaccines showcases the effectiveness of these investments.
• Establishing robust cold chain systems ensures proper vaccine storage and transportation.
• A dedicated workforce of trained community health workers provides last-mile services and outreach.
• Targeted communication campaigns address vaccine hesitancy and promote immunization uptake.
• Consistent and accurate information is delivered through various communication channels.
• Accredited Social Health Activists (ASHAs) and Anganwadi workers play a crucial role in information dissemination at the community level.
• Engagement with national leaders, celebrities, and local community influencers fosters trust and confidence in vaccines.

5. Expanded Programme on Immunization (EPI)

The Expanded Programme on Immunization (EPI) emerged in response to the need for widespread vaccination efforts, particularly with the impending eradication of smallpox. Initially introduced as a global initiative to leverage existing immunization infrastructure and trained personnel, EPI aimed to extend the benefits of available vaccines to populations worldwide. Since its inception, EPI has undergone evolution and adaptation to address changing disease landscapes and healthcare needs.

Key Objectives

The primary objectives of EPI encompassed

•  EPI aimed to prevent the spread of vaccine-preventable diseases, reducing morbidity and mortality rates associated with conditions such as measles, polio, and diphtheria.
• EPI sought to achieve high vaccination coverage rates across target populations, particularly focusing on infants and children.
• EPI prioritized the development and strengthening of immunization infrastructure, including healthcare delivery systems, cold chain logistics, and human resource capacity.
• EPI fostered collaboration among governments, international organizations, healthcare providers, and community stakeholders to facilitate the implementation of immunization programs worldwide.

Achievements and Impact

Over the decades, EPI has achieved significant milestones and made a profound impact on public health

• EPI played a pivotal role in the successful eradication of smallpox, demonstrating the effectiveness of mass vaccination campaigns.
• EPI contributed to the control and near-elimination of diseases like polio, measles, and neonatal tetanus in many regions, reducing disease burden and saving lives.
• EPI substantially increased immunization coverage rates, ensuring that millions of children received life-saving vaccines against various infectious diseases.
• EPI initiatives facilitated the strengthening of healthcare systems, enhancing capacity for vaccine delivery, surveillance, and response to outbreaks.

Challenges and Future Directions

Despite its successes, EPI continues to face challenges such as vaccine hesitancy, inequities in access, and emerging infectious threats. Moving forward, EPI must adapt to evolving health landscapes, address barriers to vaccination, and embrace innovations in vaccine technology and delivery. Additionally, EPI should prioritize expanding immunization efforts to include adults and the elderly, recognizing the broader spectrum of vaccine-preventable diseases across the life course.

6. The World Health Organization

The World Health Organization (WHO) is a specialised agency of the United Nations responsible for international public health. Established on April 7, 1948, WHO's primary objective is to promote health, monitor global health trends, provide technical assistance to countries, and coordinate international health responses. It operates under the principle that health is a fundamental human right and strives for health equity and universal health coverage.

Core Functions

 WHO fulfils its mandate through several core functions?

• WHO develops evidence-based policies and strategies to address global health challenges, such as infectious diseases, non-communicable diseases, and health emergencies.
• WHO monitors global health trends, collects health data, and conducts epidemiological surveillance to track disease outbreaks and assess health risks.
• WHO provides technical support and expertise to countries in areas such as healthcare delivery, disease prevention and control, health system strengthening, and emergency response.
• WHO sets international standards and guidelines for health practices, including the regulation of medicines, vaccines, and health technologies, as well as food safety and sanitation.
• WHO builds the capacity of health systems, healthcare workers, and communities to effectively respond to health challenges and promote health promotion and disease prevention initiatives.

Key Priorities and Initiatives

WHO addresses a wide range of health priorities and initiatives, including:

• WHO advocates for access to quality healthcare services for all, regardless of socio-economic status, through the attainment of UHC.
• WHO leads global efforts to prepare for, respond to, and mitigate the impact of health emergencies, including epidemics, natural disasters, and pandemics such as COVID-19.
• WHO addresses the rising burden of NCDs, such as cardiovascular diseases, cancer, diabetes, and mental health disorders, through prevention, treatment, and health promotion strategies.
• WHO plays a key role in controlling infectious diseases, including HIV/AIDS, tuberculosis, malaria, and vaccine-preventable diseases, through vaccination campaigns, treatment programs, and surveillance efforts.
• WHO advocates for addressing social determinants of health, promoting health equity, and reducing health disparities within and between countries.

7. Conclusion

The achievements of immunization programs over the past five decades, also call for renewed efforts to address existing challenges and expand vaccination coverage to ensure health equity for all age groups. By implementing the proposed recommendations and leveraging global partnerships, countries can strengthen their immunization programs and make significant strides towards achieving universal health coverage and disease prevention.