IMAGINE if, when a pandemic swept across the globe, scientists responded quickly to develop effective vaccines only for a small number of wealthy countries to buy up almost the entire global supply, leaving virtually none for the rest of the world. That is precisely what happened in 2009 with the H1N1 flu pandemic. We must not allow it to happen again with covid-19.

In some ways we got lucky with H1N1: the virus became less virulent over time and vaccine supplies eventually increased enough to be included in the seasonal flu shot, enabling more people to get access. The jury is still out on whether something similar will happen with the coronavirus, but, either way, a return to normality will continue to elude us until people in all countries are protected.

Thankfully, we now have several vaccines, so to end this crisis there must be rapid, fair and equitable access to them, particularly for those people living in the world’s poorest countries, which are most in danger of missing out.

This is the goal of the global vaccine coalition . Along with my colleagues at Gavi, the Coalition for Epidemic Preparedness Innovations and the World Health Organization, we are working hard to make sure that covid-19 vaccines don’t just end up going to the highest bidder. With 190 governments and economies involved, representing 90 per cent of the global population, we are now on the cusp of beginning vaccination.

This month, the first of more than 2 billion doses will start to be rolled out to high-risk individuals in 92 lower-income countries. For people in these countries to get new vaccines within a matter of weeks of those in the wealthiest nations is simply unprecedented. However, challenges still remain.

Despite working together with COVAX, governments are under immense pressure to secure doses for all their citizens. This means countries are still seeking bilateral deals with vaccine manufacturers, and these risk placing additional constraints on supplies at a time when they will be most limited. We are already seeing the consequences of this with supply shortfalls in many countries.

If governments continue with this kind of vaccine nationalism and if manufacturers only offer covid-19 vaccines to the highest bidders, just like in 2009, this will only prolong the crisis. Even if doses are promised to every country further down the line, delaying the availability of doses around the world will allow the coronavirus to continue to circulate, mutate and potentially adapt better to the human host. That works against everyone’s best interests.

While COVAX was created with the world’s poorest people in mind, it works to everyone’s benefit. For the lowest-income nations, which would otherwise be unable to afford these vaccines, COVAX is quite literally a lifeline and the only viable way in which their citizens will get access to covid-19 vaccines.

However, there are also many upper-middle-income nations that can afford to pay for their vaccines yet lack the resources to secure doses for their citizens through bilateral deals with manufacturers. And for those 35 or so governments that are wealthy enough to secure bilateral deals, it acts like an insurance policy, guaranteeing them doses if those deals should fail, but also protecting their citizens through vaccinating others. In a global pandemic, you are only safe if everyone is safe.

For six decades, a deadly pandemic has raged, killing millions of people and infecting tens of millions more. Yet because it has been eliminated from wealthy countries barely anyone in the West is aware that it is still ongoing.

Beginning in Indonesia in 1961, the current – the seventh in modern history – has persisted for six decades. It has its own strain of the bacteria that causes the disease – called El Tor – which has spread to more than 150 countries, sometimes smouldering, sometimes blazing, but never fully extinguished. Almost all of those affected today are the poor and vulnerable in disaster zones or fragile states – think of the outbreak in Haiti in 2010.

The latest flare-up is in Yemen, where at least 1500 people have died and more than 185,000 have been infected amidst war and famine. Sadly, even with to Yemen, things are likely to get worse before they get better.

For the pandemic as a whole, the prospects are also dire.

This is all the more tragic because the disease is as preventable as it is contagious. The World Health Organization (WHO) estimates that with the right strategy and funding, cholera could be eliminated from most of the world within a few years, to the point that it would no longer pose a global health threat.

Cholera hotspots

Outbreaks can be avoided by improving access to clean water, sanitation and hygiene in cholera hotspots, as well as vaccinating those at risk.

The challenge is that often these hotspots face protracted crises that limit the ability to make improvements, for example in and . In such cases immunisation has an even bigger role, provided it can be done early enough.

The good news is that we have safe, effective and affordable vaccines. Before 2011 that wasn’t the case. The only vaccine that met WHO safety and efficacy standards wasn’t suited to developing countries because it needed to be administered using clean water.

But now with support from , the vaccine alliance I head, this year will see the production of 17 million doses of a vaccine that doesn’t rely on clean water. This will also be used to maintain a global stockpile of 2 million doses for emergency use.

However, in practice, it is hard to get vaccines into crisis zones quickly enough to prevent an epidemic developing. Instead, vaccine use becomes more about control and containment.

Limited sanitation

Epidemics will become more likely, particularly in Africa, where the . This, combined with additional pressures from climate change, such as land degradation, rising seas, drought and famine, not to mention conflict, could see tens of millions of people displaced. Inevitably, more will be driven towards cities. In 1950, two-thirds of the world’s population lived in rural areas, and just a third in urban areas. By 2050, this ratio is forecast to be reversed.

More people living in less space, placing more strain on already limited sanitation and drinking water systems, will provide a . At the same time, the sheer scale of modern megacities has the potential to outstrip vaccine supplies, limiting the ability to prevent or respond to outbreaks in this way.

It doesn’t have to be like this. Yemen reinforces a crucial lesson: when it comes to cholera we need to be proactive, not reactive.

When we know there is a very high chance that the disease will appear, we need to vaccinate as soon as possible. To do so, we will need to better understand how the infection initially spreads and which vaccination strategies would be best to prevent this.

In conflict-prone areas this is even more critical, because brief periods of peace may be few and far between. And wherever it is feasible we need to improve access to clean water, hygiene and sanitation. Ultimately, if we don’t want this pandemic to last another six decades then we need to acknowledge it and treat it as a growing threat.

HOW many vaccines do you think it takes to fully immunise a child? One? Three? Perhaps five? By the World Health Organization’s reckoning, that number is 11 – that’s 11 key vaccines every child should have to protect them from a range of devastating diseases. So why then are we only using three to measure immunisation coverage? By doing so, we are not only giving ourselves a skewed perspective of the state of global childhood immunisation, but we are also in danger of thinking it’s job done, when we still have far to go.

At first glance, it appears that we have almost won this particular health battle, with the proportion of the world’s children receiving routine vaccinations climbing steadily from 73 per cent a decade ago to about 83 per cent today. But that’s only when you measure the uptake of three basic childhood vaccines, completed on the third dose of diphtheria-tetanus-pertussis (DTP). When you include all of the 11 that the WHO says every child should have, a very different picture emerges. Less than 5 per cent of the world’s children are fully immunised when you add BCG (for tuberculosis), measles, rubella, polio, hepatitis B (hep B), Haemophilus influenzae type B (Hib), pneumococcal and rotavirus vaccines.

Such a discrepancy exists because for the last three decades the global health community – governments, international organisations and aid agencies – have used just one or two “tracer” vaccines to measure immunisation coverage, usually the third dose of DTP or sometimes the first dose of measles. In the past, these worked because they not only allowed us to gauge the reach of immunisation programmes, but also, in the case of DTP, it showed the strength of countries’ health systems because it requires three contacts with those systems.

These indicators are now antiquated, limited and wholly misleading. Only a small percentage of countries still use traditional DTP, the majority having switched to modern combination vaccines like the 5-in-1 pentavalent vaccine, which combines DTP with hep B and Hib. So in fact a large proportion of the 83 per cent are actually getting five vaccines. Also, in terms of impact on reducing child mortality, DTP no longer provides an accurate picture. With the development and availability of pneumococcal and rotavirus vaccines, we can now protect children from the two biggest childhood killers, pneumonia and diarrhoea, which account for 29 per cent of all deaths in under-5s each year, or two million lives.

So by continuing to use DTP as a measure of coverage there is a danger that we become complacent. For, even though the number of fully immunised children is on the rise, based on current projections, by 2030 it will still only have risen to the point that barely more than half of the world’s children will be receiving all 11 vaccines.

If you just take the world’s 73 poorest nations – those that my organisation, the , supports, and where disease risks are highest – this 2030 figure is still only forecast to be about 70 per cent. The figure is higher there because use of all 11 vaccines is more likely than in richer nations where, for example, TB shots are no longer deemed necessary for all.

Using the new measure would almost certainly help improve the situation, but it’s not the only vaccine metric in need of a revamp. The value we place on immunisation is also failing to capture the big picture.

Typically, when we talk about the need to vaccinate children it is in terms of saving lives and preventing illness. While it does this, in the last few years we have seen a growing body of evidence suggesting that this is only part of the story; that the full benefits extend beyond protecting health and saving lives, and reach well into a child’s later life.

By avoiding multiple illnesses, vaccinated infants can grow into healthier children who are able to attend school more. And they don’t just do better at school. Through the prevention of damage that can be caused by infectious diseases, they also appear to benefit in terms of cognitive development. All this helps the family and the wider economy, with parents able to work instead of caring for a sick child, generating more income and increasing their spending power.

That is not to say that vaccines alone are the solution to fighting poverty, but rather that their role in removing some of the causes of poverty is vastly underestimated. As a public-health intervention, immunisation is already widely seen as one of public health’s “best buys”, but by measuring the effectiveness in terms of lives saved, it seems likely that we are undervaluing the benefits and the return on investment they offer.

“The role of vaccines in removing some of the causes of poverty is vastly underestimated”

More research is needed to better understand and quantify the relationship between full immunisation coverage and the range of benefits for individuals, households, communities and countries. What is clear, however, is that if more children got all 11 vaccines, the benefits would be amplified and the impact on health and poverty reduction would be profound.

GAVI is taking steps to achieve this. And if all countries were to introduce all 11 vaccines widely enough, while at the same time strengthening their routine immunisation systems, then by 2030 we could see nine out of 10 children fully immunised. But to achieve this we need to move away from antiquated indicators and look instead at finding ways to monitor the child and their full level of protection.

It is only by counting the number of fully immunised children – the number of children in the world that have received all 11 vaccines by their first birthday – that we can fully take advantage of the power of vaccines and make every child count.

This article appeared in print under the headline “The missing metric”.