The Expanded Programme on Immunization (EPI) is the World Health Organization’s programme to make vaccines available to all children throughout the world. On its fortieth anniversary, Daily Development talks to its Director about the challenges it has faced and the successes it has had over the past four decades. 

DD: What is EPI?

O-B: EPI was established in 1974 to develop and expand immunization programmes throughout the world. EPI was originally rolled out to enable vaccination and to help prevent childhood killers, such as measles, diphtheria, tetanus and pertussis. Now EPI not only protects infants from vaccine-preventable diseases, but also other age groups, for example with the HPV (human papillomavirus) vaccine for adolescent girls, the tetanus vaccine for mothers and women of childbearing age and the vaccine against seasonal influenza. 

EPI looks at the full spectrum of the immunization programme, including new product designs and vaccine formulations that simplify safe administration in resource-constrained settings; for example, the revolutionary meningitis A vaccine that was developed by WHO and PATH using a unique vaccine development model aimed at providing an effective, affordable and long-term solution to epidemic meningitis in the African meningitis belt, a large area that stretches across the continent from Senegal to Ethiopia. 

DD: What is the significance of the fortieth anniversary?

O-B: We have a mature programme, and by taking stock of what we have learned in the design, implementation, partnership, innovation and creation of this programme, we can apply it to many areas. 

Why vaccines? Because they protect lives through averting 2 to 3 million deaths per year. Vaccination is comparable to the impact of clean water in terms of disease elimination. Expanded vaccine coverage is one of the most cost-effective programmes in development. However, we still have a few key countries that are not there yet, such as Afghanistan, Nigeria and Pakistan.

DD: What are some of the greatest achievements of EPI and what are some of the challenges ahead?

O-B: When EPI was launched in 1974, less than 5% of the world's children were immunized during their first year of life against six killer vaccine-preventable diseases: polio, diphtheria, tuberculosis, pertussis (whooping cough), measles and tetanus.

Today, an estimated 83%, or about 110 million of the world's children under one year of age, receive these life-saving vaccinations every year. Increasing numbers of countries, including low-income countries, are adding new and under-used vaccines, such as against hepatitis B, Haemophilus influenzae type b (Hib) and yellow fever, to their routine infant immunization schedules. That is a huge feat.

However, I see two main challenges for EPI: access and equality.

In terms of access, the challenge is to ensure that vaccines get to those who need them the most and who are not reached today, such as children in the world’s most remote areas. Approximately 22 million children, mostly living in less developed countries, miss out on the three basic vaccinations (diphtheria, tetanus and pertussis) during their first year of life every year, although we immunize about 110 million children each year. Reaching those 110 million children is great, but we need to reach all children with life-saving vaccines. It’s about universal access to vaccines and extending the full benefits of immunization to all people, regardless of where they are born, who they are, or where they live.

The second challenge I see is providing vaccines to people in middle-income countries, who may not have access to vaccines at the same price as people in low-income countries. For example, the GAVI Alliance provides access to vaccines to low-income countries, but there are poor people in middle-income countries who cannot access those vaccines at the same low prices. The HPV vaccine, for example, is sold at a higher price to middle-income countries. 

DD: What are you most proud of in your work with EPI?

O-B: One of my favourite experiences in terms of working for EPI was when I was dealing with district planning, working towards having managers develop the skills to monitor vaccination programmes, constantly ensuring the services available to the targeted group were to the best possible standard and achieving at least 80% vaccination coverage. The eastern Democratic Republic of the Congo is where I learned the most about how such programmes can be rolled out at various levels, from the micro to the macro level (or from bench to the bush, as they say). Since the inception of EPI, immunization has been all about universal health coverage. One can trace a lot of today’s concept of EPI back to universal health coverage: progressively getting interventions to as many people as possible.

It is important for us to bring to all populations the basic interventions that will change lives, using today’s knowledge, technology and resources. We are likely to have the best impact on health if we work together. It is a matter of learning and sharing lessons.