Global Issues / March 2007

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eJournal USA

Global Issues: Volume 12, Number 3

Editor-in-Chief George Clack

Executive Editor Richard W. Huckaby

Production Manager Christian Larson

Assistant Production Manager Sylvia Scott

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Managing Editor Charlene Porter

Copy Editor Rosalie Targonski

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Reference Specialists Anita Green 

 Joan Taylor 

 Martin Manning

Contributing Editor Alexandra Abboud

Editorial Board Jeremy F. Curtin

 Janet E. Garvey

 Charles N. Silver
1 eJournal USA Global Issues / March 2007

About This Issue

Vaccines save lives and prevent disease. 

Immunizations spare children from 

crippling disabilities and afflictions that 

rob them of thriving adolescence and productive 

adulthood. Routine childhood immunization 

programs offer youngsters the opportunity for a 

healthier and more robust future. When healthy 

children mature to become active, industrious 

citizens, contributing to the well-being of their 

families and communities, their nation becomes a 

better place.

All this from a potion, injected or ingested in but 

a moment. 

This unwavering theme echoes in the articles 

which follow, repeated like a chorus by government 

officials, doctors, nurses, social workers, and 

volunteers. Vaccines are the most successful and 

cost-effective way to prevent disease known to 

medical science. 

The hard part is making sure that vaccines are 

delivered and immunizations are administered to 

the people who need them, wherever they live, 

whatever their station or economic circumstance. 

The authors who have contributed to this 

publication are all devoted to that mission, and 

efforts they describe to achieve it have been dogged, 

unrelenting, and sometimes even heroic. 

Secretary of Health and Human Services Mike 

Leavitt introduces the topic, underscoring the 

United States’ commitment to deliver the benefits 

of vaccines to regions where they are lacking. U.S. 

Agency for International Development Assistant 

Administrator Kent Hill describes the actions the 

nation has taken to build immunization programs 

in developing countries and its partnership 

with the international community to do more. 

Officials from the U.N. Children’s Fund and the 

World Health Organization describe their vaccine 

programs, and prominent researchers discuss 

their hopes for further advancement of vaccine 

technology to prevent more diseases and ease the 

suffering they cause. 

 

 The Editors

An Ethiopian infant receives a polio immunization in the town of Shire in Tigray Region 

in 2005. The male health worker administering the vaccine was a member of a mobile 

vaccination team, delivering immunizations door-to-door. He was one of 100,000 

volunteers responding to the reemergence of polio in Ethiopia in 2004. 

UNICEF/HQ05-0560/Boris Heger
Global Issues / March 2007 2 eJournal USA

Introduction

Mike Leavitt, U.S. Secretary of Health and

Human Services

Sidebar Vaccine Milestones: Edward Jenner

Reaching Every Child

Kent Hill, Assistant Administrator, U.S. 

Agency for International Development

The United States has a longstanding commitment 

to assist other nations in achieving the lifesaving 

benefits of vaccines and is working with the 

international community toward that goal.

Sidebar The World Knows How

Sidebar Vaccine Milestones: Louis Pasteur

The Promise of Vaccines

Osman David Mansoor, Senior Advisor for

New Vaccines, U.N. Children’s Fund

Vaccines are the most cost-effective means of 

ensuring childhood survival. Immunization rates are 

rising steadily as health officials work to reach more 

children every year.

Success in Measles Control

A multipartner campaign to reduce measles 

mortality achieves a five-year goal sparing children 

from the most infectious of diseases.

One Dose at a Time

An interview with Vance Dietz, Steven

Stewart, and Karen Wilkins, Coordinating

Center for Infectious Disease, U.S. Centers

for Disease Control and Prevention

Three international public health experts discuss 

how developing nations work to establish and 

maintain routine childhood immunization 

programs.

Sidebar Peaceful Days, Better Lives

Stopping Polio Forever: A Photo Story

Charlene Porter, managing editor, Global

issues

The Global Polio Eradication Initiative has made 

tremendous progress in reducing the occurrence of 

polio. Massive vaccination rallies known as National 

Immunization Days have helped achieve the goal. 

Sidebar Vaccine Milestones: Salk, Sabin, and Polio

U.S. Department of State / March 2007 / Volume 12 / Number 3

http://usinfo.state.gov/pub/ejournalusa.html

global issues

6

10

4 13

14

19

Lifesaving Vaccines

5

7

8

18

21
3 eJournal USA Global Issues / March 2007

How the World Fights the Flu

Wenqing Zhang, Project Leader for

Influenza Virological Surveillance and

Vaccine Viruses of the Global Influenza

Programme, World Health Organization

The World Health Organization coordinates 

a global effort to monitor seasonal and avian 

influenza emergencies with an eye toward 

production of vaccines that can help prevent and 

ease illness affecting hundreds of millions of people 

worldwide each year.

Sidebar Vaccine Milestones: Smallpox Is Dead

Vaccines in the 21st Century

Stanley A. Plotkin, Executive Advisor to the

Chief Executive Officer of sanofi pasteur and

senior editor of Vaccines

The inventor of the rubella vaccine offers a forecast 

of likely progress in vaccinology in the first decades 

of the 21st century. 

Ending Disease, Ending Poverty

An interview with Lee Hall, Chief, 

Parasitology and International Program, 

National Institute for Allergy and

Infectious Diseases, National Institutes

of Health; and Peter J. Hotez, Walter G. 

Ross Professor and Chair of Microbiology, 

Immunology, and Tropical Medicine at the

George Washington University and Sabin

Vaccine Institute

Overcoming diseases that have plagued humankind 

for millennia and are persistent causes of poverty is 

within the reach of 21st century medical science, 

experts say.

Sidebar A Quick Strike Against Disease

What Are Neglected Tropical 

Diseases?

Definitions and descriptions of poverty-causing 

diseases.

Ensuring the Quality and Safety of 

Vaccines 

A World Health Organization Fact Sheet

Concerns About Vaccine Safety

The National Network for Immunization 

Information addresses risks and safety.

Bibliography

Internet Resources

36

31

25

29

43

46

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40

Video Online

• Victory over Polio

Universal Newsreel

• Bangladesh Prepares for National

Immunization Days

UNICEF Television

• Vaccines: Separating Facts from Fear

The Vaccine Education Center

http://usinfo.state.gov/journals/itgic/0307/ijge/ijge0307.htm

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Global Issues / March 2007 4 eJournal USA

Prevention is the way to wellness. That’s why 

vaccines are so important. Not only can they 

prevent temporary discomfort and even permanent 

disability, they can eradicate disease and even prevent 

death. 

Since Edward Jenner began inoculating against 

smallpox more than 200 years ago, vaccines have literally 

saved millions of lives. They have completely eliminated 

smallpox as a naturally occurring disease threat. They 

have made once common diseases like measles and polio 

uncommon—or nearly nonexistent—in the countries 

where they are widely used. Vaccines can even prevent 

some types of cancer. And U.S. scientists are continuing to 

develop new vaccines against many other well-established 

diseases and emerging threats. 

The United States remains committed to developing 

new vaccines and spreading their benefits to those in need. 

Vaccines developed by U.S. researchers against one 

bacterium (Haemophilus influenzae type b, or Hib) have 

virtually eliminated a leading cause of severe pneumonia, 

meningitis, and long-term disabilities among children in 

developed countries. Studies have confirmed their safety 

and effectiveness in developed countries. Broadening the 

distribution of the Hib vaccines promises to reduce the 

global burden of infections from that bacterium, which 

causes 2 to 3 million cases of serious disease and more than 

380,000 deaths worldwide each year.

Since the Global Polio Eradication Initiative began 

in 1988, polio cases have dropped by more than 99 

percent from an estimated 350,000 in 1988 to fewer than 

2,000 cases in 2006. More than 5 million cases of polio 

paralysis and more than 250,000 polio-related deaths have 

been prevented due to the eradication initiative. Only four 

countries—Nigeria, Afghanistan, Pakistan, and India—

Introduction

U.S. Secretary of Health and Human Services Mike Leavitt visits the HIV voluntary counseling and testing center in Hai Phong City, Vietnam, 

one stop on a multinational tour of health facilities in 2005.

HHS Photo
5 eJournal USA Global Issues / March 2007

remain polio-endemic, and the United States remains a 

partner in the ongoing effort to end this crippling disease 

in these last remaining nations. 

 We’re also concerned about the emergence of diseases. 

That’s why the Department of Health and Human Services 

awarded more than $1 billion in contracts to develop cellbased technology for vaccines against both seasonal and 

pandemic influenza last year. The benefits are likely to go 

far beyond U.S. borders—not simply the new vaccines 

and the disease protection they will convey, but also the 

advanced techniques for creating them. 

Viruses and bacteria are constantly mutating, adapting, 

and attacking. So it is not sufficient to build an effective 

vaccine to defeat one disease one time. Rather, it is critical 

to sustain an infrastructure that allows new vaccines to be 

developed and new cures to be found.

The infrastructure of adaptability is more than 

buildings or benches. It is freedom and accountability; 

competition and transparency. It is the intangible things on 

which innovation and invention thrive.

The United States leads the world in the discovery and 

development of new vaccines. I’m determined that we’ll 

keep doing so: that we’ll keep creating new vaccines and 

passing on their benefits to those in need. 

Vaccines offer possibility and opportunity. That’s why 

we’ll keep working to expand their availability: to give 

people a hope, a promise, and a future.  

 Mike Leavitt 

 U.S. Secretary of Health and Human Services 

Different cultures around the world have made efforts to protect people from infectious 

diseases for hundreds of years with varying degrees of success. Records show that the 

Chinese practiced inoculation against smallpox as early as 1000 B.C. The process was to 

take a scab from a smallpox lesion, store it for a month, mix it with plant material, and 

then place the concoction in the nose of a patient. The majority of patients thus treated 

developed a milder form of the disease, and if and when they recovered, they were protected 

from future infection with smallpox. Similar practices were reported from India and North 

Africa in the 16th and 17th centuries. Some accounts credit Lady Mary Wortley Montagu, 

the wife of the British ambassador in Constantinople, with bringing this practice from 

Turkey to Great Britain in the early 18th century. The procedure was risky because those 

inoculated might contract smallpox, which could prove fatal.

Country folk in England had long known that milkmaids were likely to be spared the 

ravages of smallpox, and their resistance was somehow related to the mild pox infection they tended to acquire from 

the cows. Some physicians observed the same phenomena, but Edward Jenner carried out experiments to test the 

relationship between cowpox and smallpox in 1796. He published his results and is generally credited with being 

the discoverer of vaccination.

Jenner experimented by taking some pus from a lesion on the hand of a milkmaid and inoculating it into the 

hand of a young boy. Some weeks later, Jenner inoculated the boy with infectious material containing smallpox. Of 

course, such human experimentation would never be permitted today, but Jenner, and the boy, were fortunate. The 

experiment was a success, the boy did not become ill, and Jenner concluded that inoculation of infectious material 

from a mild strain of a disease could protect a person from a far more serious disease. 

This then is the principle of vaccination, although the scientific basis for it would not be understood for many 

decades.  

Elizabeth Fee, Ph.D., Chief, History of Medicine Division, National Library of Medicine, National Institutes of 

Health

Vaccine Milestones: Edward Jenner

Engraved portrait of English 

physician Edward Jenner 

(1749-1823).

© Bettmann/Corbis
Global Issues / March 2007 6 eJournal USA

The U.S. Agency for International Development (USAID) 

has been involved in worldwide efforts to immunize 

children in developing countries for more than three 

decades. The agency is also a member of the GAVI Alliance, 

a public-private global health partnership dedicated to 

expanding access to vaccines in the world’s poorest countries.

Kent Hill is the assistant administrator for USAID’s 

Bureau for Global Health and a member of the board of 

the GAVI Alliance. 

For more than half a century, medical science has 

recognized that widespread, routine immunization 

against infectious diseases can prevent the deaths of 

young children, sparing parents an agony that has spanned 

millennia. When children escape disease, they can thrive to 

become healthy adults, contributing to the development of 

more vibrant and productive societies. 

Knowledge is one thing. The delivery of vaccine to 

children everywhere is a vastly greater challenge. 

Since the 1970s, the U.S. Agency for International 

Development (USAID) has worked with partners across 

the globe to confront that challenge and help immunize 

children in remote and underdeveloped parts of the world. 

Reaching Every Child

Kent Hill

A doctor checks a baby girl’s respiration during a medical examination in Caquixajay, a small rural village 105 km, 65 miles west of Guatemala City, 

in November, 2004. 

© AP Images/Rodrigo Abd
7 eJournal USA Global Issues / March 2007

Over the decades tens of millions of infants and children 

have survived the momentary discomfort and dismay of 

immunization to gain protection from disease.

USAID was a partner in the 1970s campaign to rid the 

world of smallpox. USAID provided support in the 1980s 

to the World Health Organization’s (WHO) Expanded 

Immunization Programme (EPI), a campaign to expand 

access to immunization against childhood tuberculosis, 

polio, diphtheria, pertussis, tetanus, and measles. By 1990 

coverage for those six diseases reached 70 percent globally, 

and the occurrence of those preventable but often fatal 

illnesses fell dramatically. Even though the news was fairly 

good at the global level, most of Africa and Asia remained 

far below the global mark of 70 percent—clearly a problem 

that needed attention.

We have learned that the challenge never ends and the 

task is never done.

In the 1990s the levels of vaccination among 

populations leveled off and even declined in some nations. 

The momentum of the EPI slowed for a variety of reasons, 

not the least of which was a sense that the job was done. In 

economically struggling nations, other priorities demanded 

attention. Major donors turned their attentions to other 

desperate problems.

By 1999 recognition of this reversal of progress 

led to a new initiative—the formation of the Global 

Alliance for Vaccines and Immunization (GAVI) [http:

//www.gavialliance.org/]. It is an alliance devoted to saving 

children’s lives and protecting people’s health through 

the widespread use of vaccines. A powerful alliance 

of governments, international organizations, vaccine 

manufacturers, nongovernmental organizations, and public 

health institutions is devoted to creating a new model for 

the delivery of international development aid. In pursuit 

of that goal, GAVI funds programs that strengthen health 

and immunization systems and accelerate access to new 

vaccines and new vaccine technologies.

Since inception, donors have committed more than 

$3 billion to the GAVI Fund, and more than $1 billion 

has already been distributed to nations implementing 

immunization programs. The GAVI Fund has provided 

multiyear grants to 73 of the world’s poorest countries 

in order to help them build a permanent and sustainable 

system for delivery of immunizations to children. 

The United States continues to be one of the largest 

donors to GAVI, having committed more than $350 

million since the institution was created. 

In GAVI’s first five years, almost 100 million additional 

children received new vaccines, with 2006 efforts reaching 

another 38 million youngsters. WHO estimates that 

the premature deaths of 2.3 million children have been 

prevented through the efforts of the GAVI Alliance. By 

The world knows how to immunize its children, and the GAVI Alliance strives to provide the leadership and 

resources to make sure that vaccines are delivered to all the world’s children, no matter how remote their 

homes or how poor their families. 

Partners in the GAVI Alliance include national governments, from both donor nations and developing countries. 

Donors currently represented on the GAVI board are France, the Netherlands, Norway, the United Kingdom, and 

the United States. Developing nation representatives from Armenia, Cambodia, Ethiopia, and Ghana also serve on 

the board in 2007. 

The United Nations Children’s Fund, the World Health Organization, and the World Bank are also part of 

the alliance, along with nongovernmental organizations, such as the Bill & Melinda Gates Foundation and the 

International Pediatric Association. 

Pharmaceutical companies from both the developed and the developing world are partners in the GAVI Alliance 

today, with Merck and Co., Inc., now serving on the board. The vaccine manufacturers participating in this effort 

produce the greatest share of the world’s supply.  

Source: http://www.gavialliance.org/index.php

The World Knows How
Global Issues / March 2007 8 eJournal USA

reaching so many children in such a short time, GAVI is 

amplifying its global impact and paving the way for the 

introduction of future vaccines. 

The GAVI Alliance now enters a new phase in which 

we will work toward broader goals to increase global 

development assistance for health, harmonize the work of 

the partners with strategies devised by recipient countries, 

and advance new, better, and more affordable technologies 

for the delivery of immunizations and health care. 

New Technologies and Methods

Considerable success has already been achieved in 

improving the number of children reached with vaccines. 

In fact, effective and easy-to-use technologies have been 

important in the scale-up of developing world vaccination 

rates in GAVI’s first few years. For example, a vaccine 

against hepatitis B had been available and used for more 

than 15 years in the developed world before GAVI came 

into existence. As an alliance with financial backing 

from its partners, GAVI moved swiftly to make hepatitis 

B vaccine available for use in developing countries. 

Acceptance and adoption of the new GAVI- supported 

hepatitis B vaccine was astounding—reaching more 

than 90 million infants in five years—and is one of the 

first great success stories of GAVI. In addition, GAVI 

was influential in encouraging vaccine manufacturers to 

combine hepatitis B vaccine with the established vaccine 

against diphtheria, typhoid, and pertussis (DTP), allowing 

immediate inclusion of the new product into existing 

delivery systems. We are now seeing the fruits of those 

efforts as new suppliers have entered that market, resulting 

in substantial price reductions for poor countries.

For years, USAID supported the development and 

promotion of a special type of syringe known as the autodisable that is quick, convenient, and safe. It can be used 

only once, thus reducing the danger that immunization 

could expose patients to HIV or other diseases through 

syringe reuse. GAVI purchased these devices by the tens 

of millions to allow a wide introduction of these safe 

syringes into immunization programs in the world’s 

poorest countries. GAVI provided enough syringes for each 

I

n the last quarter of the 19th century, scientists identified bacteria as the cause of 

many diseases, including cholera, typhoid fever, anthrax, plague, diphtheria, and 

tuberculosis. In France microbiologist and chemist Louis Pasteur had noticed that 

cultures of fowl cholera lost their virulence if they were left inactive for two weeks. When 

chickens were inoculated with the old cultures, they did not become ill. Furthermore, 

the birds remained resistant to the disease even when they were inoculated with fresh 

cultures. He then experimented with anthrax, a disease that was killing many cows, 

sheep, and goats in the countryside. Pasteur found that by keeping the anthrax bacilli for 

two weeks at a temperature of 42 to 43 degrees Celsius, he could greatly weaken their 

virulence. 

In 1881 he and his colleagues inoculated 31 farm animals with the weakened anthrax 

cultures; a matching set of 31 animals served as controls. Several weeks later, they 

inoculated both sets of animals with fresh, virulent anthrax bacilli. Most of the control animals died, but of the 

animals given the weakened anthrax cultures, only one sheep died. Pasteur coined the term “vaccine,” after the 

Latin vacca, or cow, in honor of Edward Jenner and his milkmaids.

Following this success, vaccines were developed against tuberculosis, cholera, typhoid, and other diseases. 

Perhaps the most dramatic development was Pasteur’s vaccine against rabies, which attracted worldwide media 

attention. After testing the vaccine on dogs, in 1885 Pasteur inoculated a nine-year-old boy who had been badly 

mauled by a rabid dog. The boy’s life was saved and Pasteur was hailed as a hero.  

Elizabeth Fee, Ph.D., National Institutes of Health

Vaccine Milestones: Louis Pasteur

Louis Pasteur, a chemist and the 

founder of microbiology, works on 

an experiment.

© Corbis
9 eJournal USA Global Issues / March 2007

country program for three years, and now all countries 

have taken on the cost of those syringes for routine use in 

their immunization programs. 

GAVI has also had a positive influence on the global 

business of vaccine production by demonstrating to 

manufacturers that the developing world can be a 

profitable market. This activity has thus stimulated 

additional vaccine supply and reduced prices of some of 

the GAVI-funded vaccines in a timely manner compared 

to historical trends. 

GAVI wants to be successful in accelerating the 

delivery of newly formulated vaccines to the developing 

world. In the past, broad adoption of a new vaccine in 

poorer nations has lagged as much as 15 to 20 years 

behind developed nations. In November 2006, the GAVI 

board approved two such proposals. The decision allows 

distribution of much newer vaccines, introduced in recent 

years in the United States and Europe, that will combat 

diseases that together kill an estimated 1.5 million children 

annually. One new vaccine targets rotavirus, which causes 

severe and often fatal diarrhea, and the second prevents 

pneumococcus, a major cause of pneumonia, meningitis, 

and sepsis. 

The two vaccines will be introduced on a staggered 

scale in a limited number of countries at first to ensure the 

completion of additional efficacy studies.

Even as the United States is an enthusiastic member 

of the GAVI Alliance, USAID has independently 

supported a number of parallel initiatives. In addition to 

the development of the auto-disable syringe, USAID has 

funded clinical trials for vaccines to be used in developing 

countries and supported disease-burden assessments. To 

improve immunization technology, USAID has backed 

research to create vaccine-vial monitors, which allow 

vaccines to remain safely outside the cold chain for limited 

periods of time. This is an important advancement for 

teams attempting to deliver vaccines to remote villages 

where refrigeration does not exist or is difficult to maintain 

in transit.

Current and future research supported by USAID is 

devoted to development of a vaccine against HIV/AIDS 

that will be appropriate for use against developing world 

strains of the disease and under the prevailing conditions 

of those areas. We are also investing in research to 

develop a vaccine against malaria, a disease that is rare 

in the developed world but still takes 1 million lives in 

the developing world each year, 75 percent of whom are 

African children. A vaccine against malaria becomes an 

ever more critical need with the proliferation of malaria 

strains resistant to most known drug therapies. 

The Potential

Even as USAID, the GAVI Alliance, and developing 

world nations muster new resources and ideas on 

expanding immunization programs to reach every child, 

we have learned that the rewards of our efforts could be 

even greater than we dreamed. A 2005 study from the 

Harvard School of Public Health showed that the benefits 

of immunization have been significantly underestimated 

in the past. Not only does immunization protect children 

from illness and death at an early age, but it also protects 

the child from the long-term effects of illness on growth 

and development. Healthier children do better in school 

and become more productive and higher-earning adults. In 

fact, the study’s authors equate the value of immunization 

in a child’s life with that of primary education. 

Ensuring better health for the world’s children is a gift 

our generation must deliver to the future. 
Global Issues / March 2007 10 eJournal USA

Vaccines are the most cost-effective means of ensuring 

childhood survival. While immunization rates in 

developing countries have risen steadily in recent years, 

health officials continue their efforts to reach more children 

every year.

Osman David Mansoor, MD, is a senior advisor for 

new vaccines in the Health Section of the United Nations 

Children’s Fund (UNICEF). A public health physician, 

Mansoor came to UNICEF from the World Health 

Organization’s Regional Office of the Pacific and the 

Ministry of Health in New Zealand.

Few health interventions yield greater benefits for 

children than immunization, a proven, cost-effective 

way to reduce child death and disability rates. The 

benefits are indisputable and the consequences of failing to 

sustain and enhance immunization cannot be overstated: 

Diseases once under control will reemerge and spread to 

countries where they had been eliminated. Millions of 

children in the developing world would become sick or 

disabled. Millions would die. 

Vaccine-preventable diseases are estimated to cause 

more than 2 million deaths every year. Among those, 1.4 

million are children under five. These children are dying 

from measles (395,000), whooping cough (290,000), and 

neonatal tetanus (257,000). 

The Promise of Vaccines

Osman David Mansoor

Two health workers carry a refrigerated box containing vaccines during a two-day campaign in Gaza province in Mozambique, as both children 

and adults wait for immunizations in the background. To retain their potency, vaccines must be stored and transported at a constant, low 

temperature from the time of production to inoculation, a process known as maintaining the “cold chain.” 

© UNICEF/ HQ00-0245/Giacomo Pirozzi
11 eJournal USA Global Issues / March 2007

These numbers represent not merely statistics, but 

young lives, the human assets of a nation. When the health 

and futures of a nation’s youngest citizens are threatened by 

disease, the nation cannot thrive. 

These deaths are all the more tragic because these 

diseases can be prevented by vaccines currently 

recommended by the World Health Organization (WHO). 

An additional 1.1 million young children die every year 

from infections of pneumococcus, a bacteria that causes 

meningitis, pneumonia, or other conditions; and of 

rotavirus, which causes severe diarrhea. 

Building on the success of the globally coordinated 

smallpox eradication program, achieved in 1977, WHO 

established the Expanded Programme on Immunization 

(EPI) in 1974. Over time, the effort has led to steadily 

increasing levels of routine immunization of children. 

In fact, since 1990, more than 70 percent of the world’s 

infants have been receiving four vaccines, offering 

protection against six diseases: tuberculosis, polio, 

diphtheria, tetanus, pertussis (whooping cough), and 

measles. 

The hundreds of thousands of children still dying 

from these diseases, as noted above, give urgency to the 

remaining work that must be completed. Adding the 

available vaccines for pneumococcus and rotavirus to the 

routine immunization regimen offers the potential to 

prevent many more deaths.

With the establishment of the Global Alliance for 

Vaccines and 

Immunization 

(GAVI) in 1999 

and the renewed 

and concerted 

efforts of the 

World Health 

Organization 

(WHO), 

UNICEF, 

and other 

immunization 

partners, global 

immunization 

coverage 

has slowly 

but steadily 

improved in the 

new century. 

The additional 

investments generated by GAVI and the heightened 

attention given to immunization in the poorest countries 

are yielding results (see Figure 1). 

GAVI and its alliance partners are helping to implement 

the 1992 WHO recommendation that all countries add 

hepatitis B to their EPI schedule. As a result, by 2005 more 

than 80 percent of countries had implemented routine 

hepatitis B infant immunization (see Figure 2). Protecting 

every child, especially those born of mothers with chronic 

hepatitis B infection, prevents the development of liver 

cancer and cirrhosis in later life. 

Despite the improvements in the number of children 

who are routinely vaccinated, much remains to be done. 

In 2005, WHO and UNICEF developed the Global 

Immunization Vision and Strategy (GIVS), 2006-2015. 

The strategy sets a goal for all countries to reach at least 90 

percent of infants with all recommended immunizations 

and at least 80 percent in every district (or equivalent). 

Achieving the GIVS goals will save the lives of 4 to 5 

million children every year by 2015.

The poor and underserved in developing countries are 

consistently missing out on the life-saving protection of 

immunization. In 2005 more than 27 million children 

did not receive the three doses of diphtheria-tetanuspertussis vaccine (DTP) needed to protect them against 

those diseases and 30 million were not inoculated with the 

required doses of measles vaccine. 

Figure 1

Global Immunization Against Diphtheria, 

Typhoid, and Pertussis

World Infant Population

The graph portrays more than 25 years of progress in boosting the rates of childhood vaccination in increasing numbers of 

countries. These data focus on completion of a three-dose administration of the combination vaccine against diphtheria, 

typhoid, and pertussis (whooping cough).

Source: WHO/UNICEF estimates compiled August 2006

Industrialized Countries

100% 

90

80

70

60

50

198019811982

1983

1984

1985198619871988

1989

1990

1991

1992

1993

19941995

1996

1997

1998

19992000

2001

2002

20032004

2005

40

30

20

10

0

Latin America and the Caribbean

South Asia

Central Europe, CIS

East Asia and Pacific

Sub-Saharan Africa

Middle East and North Africa

Global Average
Global Issues / March 2007 12 eJournal USA

To improve coverage, national and district planners 

need to dedicate resources and develop specific strategies 

to reach the currently underserved populations. Many 

countries already use the Reach Every District (RED) 

approach, which seeks greater equity and availability of 

routine immunization services. 

In addition to protecting children from vaccinepreventable diseases, immunization programs reduce the 

transmission of disease in the community and protect 

the unvaccinated. For some diseases, such as polio, 

immunization can actually 

lead to total eradication—

as happened with smallpox.

Remarkable progress has 

been made in expanding 

immunization coverage and 

the effort must not wane. 

Every child, no matter 

his or her socioeconomic 

status, deserves to be 

protected from disease. 

Immunization programs 

also serve as a platform to 

deliver other life-saving 

interventions such as those 

against malnutrition, 

malaria, polio, and 

intestinal worms. Such 

an integrated approach is 

the most effective way to 

protect the health of all 

children, including the 

most marginalized. It is 

also a cost-effective way 

to build up health care 

systems to better ensure 

that progress becomes 

sustainable and is not lost. 

When this happens, the overall impact of immunization 

on child survival becomes far greater than the sum of its 

parts 

UNICEF’s Ahmed Magan, Jessica Malter, and Jeff 

McFarland also contributed to this article

The opinions expressed in this article do not necessarily reflect the views or 

policies of the U.S. government. 

200

150

100

50

0

1989

1990

1991

19921993199419951996

19971998

1999

2000

2001

2002

200320042005

Figure 2

Immunizing Infants Against Hepatitis

Number of Countries

The graph shows progress in vaccination against hepatitis B. A 1992 resolution by the World Health 

Assembly for the inclusion of protection against this disease in routine programs was a benchmark in the 

wider availability of this vaccine. The trend took another turn upward with the organization of the Global 

Alliance for Vaccines and Immunization (GAVI) in 1999.

Source: WHO/UNICEF estimates compiled August 2006 17 34 64

129

144

41

28

85

22

31

71

108

153

54

59

96

158

Number of countries introduced hepatitis B vaccine

Three-dose course of hepatitis B introduced

100

80

60

40

0

20

Percent Coverage of Infants Worldwide
13 eJournal USA Global Issues / March 2007

I

t starts with a fever and a cough. 

Then a rash begins on the face 

and spreads across the body. For 

some children, measles infection 

advances to cause pneumonia or 

brain inflammation, which can lead 

to convulsions or mental retardation. 

Measles is among the most 

contagious of diseases and kills 1 to 

3 percent of children in developing 

countries who contract it. Among 

children in refugee settings or the 

severely malnourished, the case 

fatality rate is much higher, killing 

up to one child in four with the 

illness.

A vaccine against this viral 

infection was invented decades 

ago and has been part of routine 

immunization for children in the developed world ever since. Measles vaccination progressed more slowly in the 

developing world, but over the past five years, governments of the region and international health agencies have 

made significant progress in expanding immunization programs to protect children from measles. 

In 2001 the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention 

(CDC), the American Red Cross, the United Nations Children’s Fund (UNICEF), the U.N. Foundation, and 

other organizations launched the Measles Initiative and began an accelerated measles-control program, aiming to 

reduce by half the number of deaths caused by measles within five years. 

The success of this effort was unveiled in January 2007 with the announcement of a 75 percent decline in 

deaths due to this viral disease in Africa alone and a 60 percent decline in deaths worldwide. 

“One of the clearest messages from this achievement is that with the right strategies and a strong partnership 

of committed governments and organizations,” said CDC Director Dr. Julie Gerberding, “you can rapidly reduce 

child deaths in developing countries.”

The campaign to reduce measles was based on four strategies: improving routine immunization; providing a 

second opportunity for measles vaccination through supplemental campaigns if necessary; improving measles care; 

and establishing effective surveillance. From 1999 to 2005, routine immunization coverage worldwide increased 

from 71 to 77 percent. This increased coverage, together with national measles vaccination campaigns in more 

than 40 countries, prevented an estimated 2.3 million measles deaths during that period. 

The progress against the disease in Africa alone is considered unprecedented. In 1999 WHO estimated that 

506,000 measles-related deaths occurred in the African region. In 2005 an estimated 126,000 deaths occurred, 

representing a 75 percent reduction, according to research presented in the January 20, 2007, edition of The 

Lancet. 

In the more than 40 countries involved, technical and financial support for these activities was provided by 

national ministries of health and the Measles Initiative (see http://www.measlesinitiative.org).  

Success in Measles Control

Wearing the slogan “vaccinate children against measles” on his shirt, a health worker 

registers schoolchildren during a 2006 measles immunization campaign in Sudan. Amid 

continued insecurity and logistical challenges in the region, Sudan is working to vaccinate 

some 4.5 million children between six months and 15 years of age by the end of 2007.

© UNICEF/HQ06-0921/Mariella Furrer
Global Issues / March 2007 14 eJournal USA

Achieving universal, routine childhood immunization has been 

a goal pursued with dedication by many agencies, donors, and 

individuals for decades. It’s a goal easily stated, but one that is 

achieved and sustained only with extensive logistical activities, 

supplies, equipment, and personnel.

Global Issues managing editor Charlene Porter discussed the 

challenges of establishing routine immunization programs with 

specialists at the Global Immunization Division of the U.S. 

Centers for Disease Control and Prevention (CDC) in Atlanta, 

Georgia. Dr. Vance Dietz is chief of the Global Measles Branch. 

Steven Stewart is a health communications specialist. Karen 

Wilkins is a public health advisor.

These three CDC professionals have worked extensively in 

Africa, Central and South America, and South and East Asia, 

helping communities in developing nations strengthen their 

childhood immunization programs. Collectively they have spent 

more than 30 years working to protect children from vaccinepreventable diseases. 

Question: Large-scale immunization programs are found 

in all developing countries with functioning governments, 

but what are some of the difficulties that developing 

countries have in sustaining universal vaccination programs?

Dietz: One of the principal issues in sustaining programs 

is having good political commitment. This is crucial to 

ensure that sufficient funding is available for immunization 

programs. Another important issue for sustaining programs 

is the presence of technically competent staff of sufficient 

One Dose at a Time

An Interview With Vance Dietz, Steven Stewart, 

and Karen Wilkins

A biologist works in the Parasitic Diseases Laboratory at the U.S. Centers for Disease Control and Prevention in Georgia. The 

laboratory houses approximately 40 employees who provide state-of-the art diagnostic services to support investigation of 

parasitic disease outbreaks and research on these diseases. 

© AP Images/Gregory Smith
15 eJournal USA Global Issues / March 2007

number to run, manage, and guide these immunization 

programs. 

Countries also need a sufficiently developed 

infrastructure with broad geographical coverage to 

actually deliver needed vaccinations and provide access to 

immunization services. 

That being said, in almost every country, the 

infrastructure cannot reach all of its population either due to 

geographical isolation, such as in mountainous areas or river 

areas, or to poor urban slums. So an immunization program 

needs a strategy to reach those who do not have access, some 

sort of outreach strategy.

These are the key issues, and they become more acute 

during times of crisis; for example, when there’s war, famine, 

civil unrest, or natural disaster. Inherent issues regarding the 

infrastructure and political commitment are the primary 

determinants, and in times of crisis they become more acute. 

Q: Lacking some of these elements or in the face 

of crises, have you seen countries lose ground in their 

immunization programs?

Dietz: Yes. Colombia, for example, had a very good 

immunization program up to the late 1980s. They were 

innovative and the leaders in immunization in the region. 

Then, with the widening of the civil war that spread 

throughout rural areas, it wasn’t safe for immunization teams 

to enter and vaccinate kids. That situation led to a downfall 

in many areas of the immunization program. So that’s an 

example of how immunization suffers in wartime. 

Then there’s the case of diminishing 

political commitment. In the early 1990s, 

Venezuela mounted immunization 

programs through the measles elimination 

initiative in the Americas. They 

implemented many of the strategies, 

successfully reached very low levels of 

disease occurrence, and had an absence 

of circulation of measles. Then, from a 

lack of follow up and a lessened political 

commitment to fund the program, the 

immunization coverage fell and there was a 

huge outbreak of measles in 2002. 

Stewart: When people are displaced 

because of natural disasters, they’re at 

high risk from infectious diseases. We’ve 

seen that in earthquake areas in Pakistan, 

after the 2004 tsunami in Indonesia, and 

in other serious disasters. If there is quick 

response from the ministry of health and 

international donors to provide immunization services, you 

can prevent outbreaks. 

Wilkins: I would just add one thing. When we talk 

about political commitment, we don’t mean solely at 

country level. The international community also has an 

important role to play. Through the 1980s, right up until 

1990, the World Health Organization’s [WHO] Expanded 

Immunization Programme [EPI] had a lot of donor support, 

a lot of focus on immunization, and rates of coverage 

increased fairly rapidly. Then the donors got tired of that 

and went on to other things, so countries were left on 

their own. Or in some cases, donors brought in new and 

different priorities and were funding different initiatives in 

the countries. So the immunization coverage did backslide 

in a lot of countries that hadn’t built up their own interest in 

immunization. 

Things are turning around now, but the international 

community has a role to play in sustaining political, longterm commitment to help strengthen these programs, create 

the demand, and make sure the infrastructure is stable.

Dietz: I think the landscape has changed from the days 

when a handful of donor nations and U.N. agencies led the 

global immunization effort. I think the formation of the 

Global Alliance for Vaccines and Immunization [GAVI] 

has been responsible for it in a lot of ways. A variety of 

partners are providing funding and new initiatives are on the 

horizon. 

Q: Let’s go from this overview down to the micro view. 

A mother and son meet with a UNICEF physician at a health outreach center on a 

remote island in the Bay of Bengal. The 2004 Indian Ocean tsunami killed an estimated 

3,500 people in the Nicobar archipelago. In the disaster aftermath, international donors 

have continued their work to provide basic food, shelter, and medical supplies; prevent 

malaria and other airborne diseases; and immunize children under five years of age. 

© UNICEF/ HQ05-0750/Pallava Bagla
Global Issues / March 2007 16 eJournal USA

What are the challenges faced by a clinic in a rural area of a 

developing country that is just beginning to establish itself 

as a provider of regular immunizations?

Wilkins: Dr. Dietz mentioned earlier that the staff in 

this clinic must be qualified. They need to have training. 

They need to be supervised. They need to have the vaccine. 

They need to have needles and syringes. They need to keep 

those supplies cold, so they need to have refrigerators at least 

within a reasonable distance, and different countries define 

that differently. They also need to have created the demand 

among the mothers, so they have clients. The mothers, the 

children, the fathers have to accept immunization because in 

some countries some people might actually block mothers 

from taking children to receive vaccinations. 

Buildings where clinics are housed are in some cases 

fairly rudimentary. They may be one room; they may be five 

rooms. They might just have a table underneath a tree, or 

they might be vaccinating in someone’s house. It depends 

very much on where they are. But the absolute requirements 

are the trained personnel, needles, syringes, cold vaccines, 

and training.

Q: Let’s pursue the demand question, the willingness of 

the community to accept immunization as a good thing. 

How difficult a hurdle is that in the countries where you 

have worked?

Wilkins: Most of my experience has been very positive. 

People not so long ago saw whole villages wiped out 

due to measles, and the survivors remember that. If they 

understand that the vaccine prevents disease, they bring 

their children when immunizations are offered. And they’ll 

come from a very long distance under adverse conditions. 

This has been my experience in the Democratic Republic of 

Congo and Burkina Faso. 

Generally the demand is there if the mother knows what 

the vaccine does, where it is available, and when it is given. 

People who don’t finish vaccination series are asked why in 

surveys. It’s typically because the mother either didn’t know 

that she needed to vaccinate her child or mistakenly thought 

she and the child had finished the vaccination series.

Very rarely did mothers say they were afraid of an adverse 

event occurring as a result of the immunization. 

Stewart: I agree. Once the knowledge is there about the 

value of vaccine, parents, particularly mothers, will go to 

great extremes to ensure their kids get immunized, walking 

great distances to vaccination sites, that kind of thing. It’s 

really quite heroic some of the measures that people take. 

But there are exceptions to that. We’ve seen, particularly 

with the polio program in recent years, examples where 

rumors can spread. This happens most easily among 

illiterate populations. In places like northern India and 

northern Nigeria, rumors that a particular vaccine is harmful 

to a child’s health, or that it may cause sterility or even HIV, 

may prevent people from participating in an immunization 

program. 

Dietz: One personal experience of mine on this subject—

I remember working in Mexico in the state of Sinaloa 

with seasonal migrant workers from the mountains of 

Oaxaca and Chiapas in the south. They were all indigenous 

populations. Many of them don’t speak Spanish and don’t 

acknowledge Western medicine. We would have vaccination 

teams going to these camps of migrant workers, and the 

mothers would actually pick up their kids and run from the 

vaccinators because they were afraid, not just of the vaccines, 

but of any Western medicine. I think that’s becoming less of 

an issue as time goes on, but it is something that can happen 

in isolated, indigenous populations who don’t have a lot of 

interaction with Western medicine.

Q: How do these immunization efforts with their 

outreach to rural areas and isolated populations serve as a 

stepping stone to the delivery of higher levels of medical care 

through these same facilities?

Dietz: In many countries immunization programs are the 

most developed of any public health program, offering the 

greatest coverage of the population. A fundamental strategy 

of immunization programs is to reach the hard-to-reach or 

the isolated, so these programs begin as outreach, but then 

it’s really important that they take other needed services 

or therapies to the community. One example of outreach, 

when we do mass immunization campaigns, we’re also 

providing insecticide-treated bed nets to prevent malaria 

infection, vitamin A tablets to prevent blindness, and 

deworming medication. It’s important that immunization 

services do that. 

Wilkins: Outreach works to benefit both programs. 

It’s being built on the platform of WHO’s Expanded 

Immunization Programme because of the greater reach 

achieved through those programs, as Dr. Dietz mentioned. 

But we’re finding in some places, people have turned out 

for immunization campaigns enough times before that now 

they’re making the trip to get that antimalarial bed net. Or 

perhaps, they wouldn’t have come for a drop of vitamin A, 

but they would come for a vaccine, so they get both. We’re 

finding it’s working to the benefit of both programs, and 

we’re exploring with WHO and UNICEF [United Nations 

Children’s Fund] ways to further advance those synergies.
17 eJournal USA Global Issues / March 2007

Q: What has been CDC’s ongoing role to help 

developing countries improve immunization services and 

extend programs to more and more children?

Dietz: CDC works through WHO and UNICEF in 

what’s referred to as a multilateral manner, meaning that we 

go through these U.N. agencies, and they provide the global 

coordination and global recommendations which help 

standardize policies and procedures. 

CDC provides financial support for routine 

immunization strengthening as well as substantial amounts 

for polio eradication and measles and rubella control. 

Much of the money for measles and polio goes directly for 

the actual purchase of vaccine. 

We also provide a considerable 

amount of technical assistance. 

We have staff that are actually 

seconded to WHO and UNICEF, 

assigned to headquarters of those 

agencies, and to regional and 

national WHO offices, which 

work directly with ministries of 

health to assess immunization 

programs and provide guidance 

on how to strengthen them. We 

are also very heavily involved in 

training surveillance staff and 

data managers at all levels in a 

health ministry, as well as staff 

who administer vaccines. We’re 

also helping to and developing 

training materials, working with 

other countries at the national and 

district levels. 

Stewart: Also, in the Global 

Immunization Division here in 

Atlanta, CDC has people who 

assist countries with developing 

annual plans of action, or even 

multiyear plans of action—what 

goals and objectives the country wants to have for the 

immunization program over a period of time, and what 

strategies will best meet those objectives.

CDC public health specialists go out to other countries 

to help plan large-scale vaccination campaigns and activities 

that will help enhance routine coverage. We’ll go out 

and monitor large-scale campaigns, as well as look at the 

performance of routine services. So there are folks at CDC 

who spend between two and six months abroad each year 

to help strengthen immunization programs with individual 

countries.

Q: What are some of the greatest recent successes in 

your mind in this entire global endeavor to expand routine 

childhood immunization? 

Dietz: One of the most recent and important 

achievements involves our measles mortality reduction 

activities. This was the result of work by the Measles 

Initiative, a partnership involving the United States, U.N. 

agencies, and other organizations. We worked in priority 

countries to halve the amount of measles-related deaths 

by 2005 compared to 1999. The 

data suggest that that goal has been 

achieved ahead of time and under 

budget—that globally there is 

actually a 60 percent reduction in 

mortality. 

Stewart: The 20-year campaign to 

eradicate polio is certainly one of 

the most significant achievements in 

this area too. CDC is a spearheading 

partner in that initiative—along 

with WHO, UNICEF, and Rotary 

International—and we estimate that 

about 5 million cases of paralytic 

polio have been prevented because 

of the polio eradication initiative, 

and probably at least a quarter of 

a million polio deaths during that 

period as well. 

Q: Those are meaningful 

statistics, but as professionals who 

have worked many years towards 

these goals, is there a particular 

place where you have seen progress 

that heartens you in this work?

Wilkins: I was a teacher in the 

Peace Corps in what’s now the 

Democratic Republic of Congo [DRC] starting in 1978. 

In 1980 the doctor at the hospital recruited me in to start 

routine immunization with him in the health zone I was 

working in. We went around from village to village to 

village—him driving the car, his wife and the hospital nurses 

giving some vaccines. We were his entire team, just driving 

from village to village. People came from every direction to 

get vaccinated in response to this modest effort started by 

An eight-year-old girl shows her vaccination certificate 

at a health center in Guinea Bissau. International 

assistance has helped to more than double the number 

of Guinean children receiving immunization coverage 

since 2001. 

© UNICEF/HQ92-0363/Giacomo Pirozz
Global Issues / March 2007 18 eJournal USA

just one individual. At that time, programs existed mainly in 

the cities and a few zones, like the one I was in, where one 

person with initiative and a vehicle would start a vaccination 

program on his own.

Years later in 1988, my first job with CDC was to go 

back to DRC and work in the immunization program. By 

that time, there were 306 health zones in the country and 

175 of them were considered functional. So the Congolese 

went from coverage that was probably 11 percent to 38 

percent by 1990. 

Now, despite all of the war and the conflict and 

everything that’s gone on in the D.R. Congo, almost every 

zone—they have 515 zones by now—503 of them are 

considered functional, providing routine immunization 

services. Their routine coverage of the childhood population 

is now 70 percent for measles. That’s not quite up to the 

90 percent level that we want every country to achieve. But 

they’ve come so far from just 20 years ago. They’ve gone 

through all these years of political unrest and managed, 

despite that, to bring people together in the rebel health 

zones and in the government health zones to continue to 

vaccinate children and improve their program. 

I

mmunization saves the lives of children, a fact so widely recognized that it has influenced events over the 

past 20 years in ways that diplomats, dialogues, and weapons have not. Appeals to protect the children have 

convinced warring factions to lay down their arms and rebel forces to open their strongholds to those who deliver 

vaccines to children in remote areas.

These negotiated lulls in fighting are known as “Days of Tranquility,” and since 1985 warriors in bitter conflicts 

have agreed to temporary truces to make way for massive vaccination campaigns. 

It began in 1985 amidst a wrenching civil war in El Salvador. Government security forces and rebels put away 

their arms for three days to allow 250,000 children to be vaccinated against polio, measles, diphtheria, tetanus, 

and whooping cough. 

Lebanon in 1987, Sudan in 1989, Sierra Leone in 1998, Burundi in 2002—in these and dozens of other 

places in the more than two decades since the El Salvadoran war, temporary pauses in fighting have been 

negotiated for the sake of protecting children from disease. 

At a U.N. conference in 2004, Sierra Leonean delegate Elisabeth Levalie described how health advocates 

managed to get to children for vaccinations in hard-to-reach conflict areas. “We had to immunize in the rebel-held 

areas. So we had to devise strategies: how to get to those people, how to build the confidence that is needed.” A 

variety of tactics and contacts were used to create peaceful corridors, she said. “We used relatives of the rebels who 

were in government areas to take the message to them, we used women’s groups, we did advocacy.”

More than 20 years after they first began, Days of Tranquility serve as an oasis of peace where immunization 

can be safely delivered by thousands of vaccinators—44,000, in fact, in a November 2006 immunization 

campaign conducted in Sudan. 

UNICEF representative Ted Chaiban worked to orchestrate that campaign, calling upon violence-prone 

communities to ensure the safety of health workers. “Safeguarding a child’s health rises above any political 

differences that may exist in communities,” he said as the campaign to reach almost 8 million children began. “It 

is imperative that where fighting continues, vaccinators and monitors are guaranteed safe access, and parents are 

able to present their children for vaccination.” 

Peaceful Days, Better Lives
19 eJournal USA Global Issues / March 2007

In the entire history of medicine, only one disease has been 

eradicated through human efforts. Deadly and disfiguring 

smallpox was eliminated as a scourge to humankind in 

1980. A vaccine made that achievement possible.

Since 1988 a second campaign has been underway to 

rid the world of a killer disease, and once again a vaccine 

is the tool that can purge a virus that has caused so much 

human misery. Charlene Porter is the managing editor of 

Global Issues.

The Global Polio Eradication Initiative (GPEI) 

brings together a vast network of expertise, 

resources, and volunteers, waging a global 

campaign against a lethal virus that can paralyze a child or 

young adult within hours, then lead to death or lifelong 

disability. The GPEI is considered the largest public health 

initiative the world has ever known.

The success of this 18-year-old campaign has been 

steady. Poliomyelitis appeared in 125 countries in the late 

1980s; now the virus is endemic—occurs in nature—in 

only four countries. Twenty years ago about 350,000 

people were stricken by polio each year worldwide. At 

press time, 1,985 polio cases were known to have occurred 

in 2006.

The 2006 case total reflects vast progress since the 

1980s, but it also underscores the importance of diligence 

in disease eradication. The number of cases in 2006 is 

higher than the worldwide annual tolls in the early years 

of the decade, when fewer than 800 annual cases were 

detected.

Stopping Polio Forever: A Photo Story

 Charlene Porter

Children disabled by polio go to an educational and rehabilitative school in New Delhi. India is one of only four remaining nations where wild 

poliovirus still occurs in the environment. More than 670 cases occurred there in 2006. 

Photo Jean Marc Giboux
Global Issues / March 2007 20 eJournal USA

Diligence is required from tens of thousands of health 

workers, volunteers, villagers, and parents, all willing to 

make sure that every child receives the multiple doses of 

vaccine required to stop the disease. That’s every child, 

including those born tomorrow, next month, next year, 

and the year after that.

Ensuring the protection of every child everywhere is a 

goal often pursued with the precision and planning of a 

political or military campaign. 

National Immunization Days (NIDs) are events 

staged in countries remaining at risk for polio. Public 

health professionals and thousands of volunteers mobilize 

mountains of supplies and resources and take them to 

every isolated corner in their countries to make sure that all 

youngsters under age five swallow the few drops of liquid 

that can protect them from crippling disease. In 2005, 400 

million children were vaccinated in 49 countries during 

NID events that lasted mere days. 

“It is a huge, huge, huge undertaking,” said Deepak 

Kapur, the National PolioPlus committee chairman for 

Rotary International in India. Rotary is an international 

nonprofit service organization that first envisioned 

the possibility of a polio-free world. Since 1985 the 

organization has been a partner working with international 

A three-year-old girl is held by her mother in September 2000 as she receives the inaugural polio vaccination dose by a local administrator, in the 

Baidoa region, Somalia.

Children flock around Dr. Kanwaljit Singh as he immunizes children in 

India’s Bihar state during a 2006 National Immunization Days event. 

In one vaccination campaign, Singh went on a journey that involved 

“crossing two branches of the Kosi river by boat, walking across 

flooded plains for 15 kilometers and crossing by foot three small 

tributaries where water levels ranged from knee high to chest high, for 

a six footer [1.8 meters] like me!” 

Photo Courtesy Kanwaljit Singh © AP Images/Sayyid Azim
21 eJournal USA Global Issues / March 2007

Poliomyelitis has afflicted humankind since ancient times, causing 

muscle wasting, paralysis, and sometimes death. In the 1940s, 

scientists found that the poliovirus exists in three basic types and that 

it can be grown in tissue cultures. American researcher and physician 

Jonas Salk killed the poliovirus with formaldehyde and produced a 

vaccine. In 1954 the United States launched a nationwide testing of 

the vaccine with the mass inoculation of hundreds of thousands of 

schoolchildren. In what has become known as the Cutter incident, 

200 children caught polio and 11 of them died. All the cases were 

traced to a single poorly made batch from one drug company. More 

careful production standards were developed and the vaccinations successfully resumed; as a result, the numbers of 

children paralyzed by polio fell dramatically. 

Whereas Salk’s vaccine was a killed-virus vaccine, Polish-American physician Albert Sabin developed a livevirus vaccine, using a weakened or attenuated form of the live virus. Whereas the Salk vaccine was used in the 

United States, 10 million children in the Soviet Union received the Sabin vaccine in 1959 in a World Health 

Organization test. Because it was relatively easy to produce and because it could be taken by mouth—often on a 

sugar cube—instead of by injection, the Sabin vaccine soon became the most popular polio vaccine around the 

world. Continued vigilant and coordinated use of the Salk and Sabin vaccines has now eradicated polio from most 

of the world’s nations.  

Elizabeth Fee, Ph.D., National Institutes of Health

health organizations, providing the energies and 

commitment of its 1.2 million members around the world.

“Vaccinators are, by and large, hopeful and 

determined,” said Dr. Kanwaljit Singh, a medical officer 

with the Indian National Polio Surveillance Project, who 

has been involved with the NIDs for more than a decade. 

“The mood at the immunization booths [set up in public 

places] is often festive and cheerful, with colorful buntings 

and banners, and the hustle and bustle of children playing 

and bringing their younger siblings for vaccination.”

If children are not presented at the booths in the parks 

and markets, vaccination teams set out on house-tohouse surveys to find every child. “It’s quite an exciting 

experience, and quite a frustrating one at times,” said 

Kapur. “At times, you’re welcomed, and they’re happy that 

you’ve traveled all the way, and very grateful that you’ve 

come in and are there to immunize their children.” But 

Kapur has also encountered parents who don’t welcome 

the immunization team, parents who hide their children to 

avoid the vaccine out of fear it will harm the youngsters.

Those unsubstantiated fears have been sown in many 

places, but when they occurred in Nigeria in 2003, a 

setback in the global eradication effort occurred.

“In certain villages, they heard the leadership say [the 

vaccination] will affect their children,” recalled BusuYi 

Onabolu, deputy chair for National PolioPlus for Rotary 

International in Nigeria.

The virus moved swiftly into a vulnerable population 

that avoided immunization. In 2004 the number of polio 

cases doubled in Nigeria, and 12 other nations, previously 

declared polio-free, experienced a reappearance of the 

disease, which genetically linked to the strain that had been 

let loose in Nigeria.

Significant negotiation and discussions calmed the fears 

about the vaccine, Onabolu said, and in August 2004 

allowed resumption of massive inoculation campaigns, 

which are held periodically until today. But Nigeria’s battle 

against polio ended 2006 with more than 1,000 cases, 

almost 40 times the number of cases in 2000. 

“We are inching forward; we believe that polio 

eradication will now be in sight in this country,” Onabolu 

said. “We cannot afford to let all those years go to waste, 

can we?” 

Vaccine Milestones: Salk, Sabin, and Polio

Pioneers of the polio vaccine were honored with a 

U.S. commemorative stamp in 2006.

© AP Images/U.S. Postal Service
Global Issues / March 2007 22 eJournal USA

“...a huge, huge, huge undertaking”

A polio campaign is conducted in Yemen’s remote highlands. Yemen is one of 14 countries where polio cases appeared in 2006 as a result of 

reimportation of the virus, years after it was thought the disease was eradicated. 

Mothers and infants wait for polio immunizations at Takai in Nigeria’s Kano state. 

This July 2004 event marked the state’s resumption of vaccination after an 

11-month ban. The ban allowed a resurgence of disease and the migration of the 

virus into other African nations. 

A Muslim religious leader vaccinates an infant 

against polio at a UNICEF-supported health center 

in a poor settlement on the outskirts of Kinshasa, 

Democratic Republic of the Congo. 

Photo Jean Marc Giboux

UNICEF/HQ05-2147/Giacomo Pirozzi

© AP Images/Saurabh Das
23 eJournal USA Global Issues / March 2007

An American volunteer from Rotary International 

immunizes children at a school in India’s Utter Pradesh 

state in 2004. Rotary was one of the founding partners of 

the GPEI and has contributed more than $616 million to 

the effort, along with hundreds of millions of 

volunteer hours. 

Photo Jean Marc Giboux

Cambodian health authorities enlist elephants equipped with loudspeakers to 

announce National Immunization Days in Phnom Penh in 1997. 

© AP Images/Ou Neakiry 

© AP Images/Irwin Fedriansyah

Indonesian 

mothers and 

children queue 

for polio 

vaccination 

near Jakarta in 

2005. A massive 

immunization 

campaign was 

organized when 

polio reappeared 

after a 10-year 

absence. 

Two volunteers prepare for a door-to-door 

immunization effort, carrying insulated boxes of vaccine 

for use in an NID in Hamer district in southern Ethiopia 

in 2005. The event targeted 15 million children after an 

upsurge in polio cases, traceable to the suspension of 

polio vaccinations in northern Nigeria in 2003-2004. 

UNICEF/HQ05-1295/ Indrias Getachew

Video Online

• Bangladesh Prepares for National

Immunization Days

UNICEF Television

http://usinfo.state.gov/journals/itgic/0307/ijge/ijge0307.htm
Global Issues / March 2007 24 eJournal USA

When the epic challenge 

to eradicate polio 

was first shouldered 

by the Global Polio Eradication 

Initiative in 1988, the goal was 

set to complete the task by 2005. 

That deadline has slipped past, 

but the campaign has not flagged. 

International partners and the 

four remaining polio-endemic 

nations renewed their commitment 

to end the transmission of polio 

worldwide at a February 2007 

meeting in Geneva. A final attack 

on the poliovirus emerged from 

the consultation, along with a 

plan to raise the money to achieve 

that end. Hundreds of millions of 

dollars are required annually for the 

four nations with endemic virus to 

immunize about 250 

million children each 

year. That diligence 

is required to ensure 

that youngsters are 

protected from the 

disease. 

The battle against 

this crippling disease 

may be hardest fought 

in these four final 

countries, and it 

may require several 

more years. Still, the 

eradication of polio in 

189 nations—and the 

health of the children 

who live there—is no 

small achievement for 

this 19-year campaign.

Eradication in Sight

World Polio in 1988

Source: UNICEF 

Active Polio March 2007

Endemic Countries

Reinfected Countires

Source: UNICEF 
25 eJournal USA Global Issues / March 2007

The World Health Organization coordinates a global effort 

to monitor seasonal and avian influenza emergencies for 

the production of vaccines that can help prevent and ease 

illness affecting hundreds of millions of people worldwide 

each year.

Wenqing Zhang, MD, is project leader for the Influenza 

Virological Surveillance and Vaccine Viruses of the Global 

Influenza Programme of the World Health Organization, 

based in Geneva, Switzerland.

Every year more than 250 million doses of influenza 

vaccine are produced that help to protect the 

world’s population against influenza infections. 

For more than 50 years, the process by which an effective 

vaccine is developed and manufactured has relied on 

the international cooperation of a wide range of public 

health partners brought together under the coordination 

of the World Health Organization (WHO) in the Global 

Influenza Surveillance Network.

Influenza is caused by a virus that is passed easily from 

person to person, most often through droplets and aerosols 

created by people when they cough or sneeze. Usually the 

virus infects mainly the upper respiratory tract, the nose, 

throat, and bronchi, but in severe cases, the virus can 

spread to the lungs. Most people recover within one or two 

weeks without the need for medical treatment; however, 

for the very young, the elderly, and those suffering from 

How the World Fights the Flu

Wenqing Zhang

This colorized, microscopic view depicts the avian influenza H5N1 virus in gold, grown in another cell medium shown 

in green. Increasing numbers of human infections from H5N1 occurring since 2004 caused health officials to become 

concerned that this virus, or one like it, has the potential to spark a global influenza pandemic with widespread human, 

social, and economic costs.

CDC/Courtesy of Cynthia Goldsmith, Jacqueline Katz, and Sherif R. Zaki
Global Issues / March 2007 26 eJournal USA

certain medical conditions, influenza can pose a serious 

risk to health and can result in other complications such as 

pneumonia and even death. 

Influenza causes outbreaks and infections throughout 

the world. In regular “seasonal” epidemics, up to 15 

percent of the population can be affected, resulting in up 

to 500,000 deaths every year. In the tropics, influenza 

outbreaks occur year-round. The principal and most 

effective measure for preventing influenza is annual 

vaccination. Influenza vaccines have been in use for more 

than 60 years, and they have been proved safe and effective 

in preventing both mild and severe outcomes of influenza. 

Each year, it is thought, influenza vaccines can reduce the 

risk of serious illness or death in the elderly and reduce 

illness by up to 90 percent in healthy adults, resulting in 

substantial health and economic benefits.

The antigenic properties of a virus are the characteristics 

that will induce the response of the body’s immune system 

to infection by the virus. By their very nature, influenza 

viruses are constantly undergoing antigenic changes. This 

means that the composition of influenza vaccines must be 

reviewed and adjusted each year to ensure that they match 

the antigenic properties of the viruses in circulation.

A Global Network

Worldwide monitoring of influenza viruses through 

surveillance is the mechanism by which the evolution of 

circulating viruses can be monitored. In 1952 a WHO 

expert committee recommended the establishment of an 

extensive international network of laboratories to conduct 

the necessary surveillance and provide WHO with the 

information it required to advise its member states on 

the most effective influenza control measures. The WHO 

Global Influenza Surveillance Network, or GISN, has been 

in operation ever since, functioning in all regions of the 

world under the coordination and administration of WHO 

headquarters.

GISN now includes more than 110 National Influenza 

Centres (NICs) located in 87 different countries and areas 

around the world, as well as four highly specialized WHO 

Collaborating Centres for Reference and Research on 

Influenza. These four Collaborating Centres are located 

in Atlanta, Georgia, United States; in London, United 

Kingdom; in Melbourne, Australia; and in Tokyo, Japan. 

Another Collaborating Centre in Memphis, Tennessee, 

United States, is focused primarily on studying the ecology 

of influenza in animals.

The NICs are the backbone of GISN. They are 

laboratories that have been designated by their country’s 

top health officials as the national focal point for influenza 

surveillance with the necessary capacity and expertise to 

perform their role. An NIC is responsible for collecting 

or receiving specimens and viruses obtained from patients 

who are ill. Every year more than 175,000 clinical 

specimens are collected from patients worldwide. Some 

of these specimens yield viruses through a process known 

as viral isolation. The NIC undertakes a preliminary 

analysis and then forwards some virus isolates thought to 

be representative of viruses circulating in the population 

to one of the four specialized Collaborating Centres for 

further characterization. 

An NIC is the key point of contact between WHO 

and a given country’s health authorities on any matter 

regarding the surveillance of influenza. The NIC informs 

WHO Photo/Garrett Smythe

Virus samples are prepared at one of the National Influenza Centres 

participating in the global network of laboratories monitoring annual 

changes in influenza viruses. 
27 eJournal USA Global Issues / March 2007

WHO and other members of GISN about viruses in 

circulation, unusual viruses that may have been detected, 

and important or unusual outbreaks. It produces weekly 

reports on influenza activity in the country during the 

influenza season, which are published in the WHO Weekly 

Epidemiological Record [www.who.int/wer], and provides 

information on the influenza epidemiological situation 

to FluNet [www.who.int/flunet], a Web-based tool for the 

support and coordination of national and global influenza 

surveillance and reporting. 

Many NICs also provide training and technical support 

to other network members in the region on the collection 

of specimens and the preliminary characterization of 

influenza viruses. 

Ensuring Effective Vaccines

The four specialized WHO Collaborating Centres 

receive influenza virus isolates from NICs around the 

world and conduct advanced analysis of the antigenic 

and genetic profile of the viruses. This information 

helps to assess the significance of the antigenic changes 

among recent circulating viruses and determines whether 

current viruses differ substantially from existing vaccine 

viruses. The centres also help to monitor the evolution 

of the viruses and their ongoing susceptibility to 

influenza antiviral drugs. They also conduct serological 

studies in collaboration with other key national 

reference laboratories, such as the Center for Biologics 

and Evaluation and Research of the Food and Drug 

Administration in the United States, the National Institute 

for Biological Standards and Control in the United 

Kingdom, and the Therapeutic Goods Administration of 

Australia. In these serological studies, the antibodies that 

develop in response to current influenza vaccines are tested 

to ascertain whether viruses contained in the vaccines still 

match circulating viruses. That information is critical to 

knowing whether the existing composition will need to be 

updated in order to have an effective vaccine for the next 

season. 

 Twice a year, WHO convenes a consultation 

between the Collaborating Centres and the key reference 

laboratories involved in influenza vaccine selection and 

development to review the results of recent analysis. 

WHO is then able to recommend which influenza viruses 

should be used in the development of influenza vaccines 

The most dramatic vaccine success story in the more than 200-year history of 

vaccines is the eradication of smallpox in 1980. Smallpox was targeted for 

eradication for several reasons: It was transmitted from human to human and had 

no animal reservoir; an effective heat-resistant freeze-dried vaccine existed that could 

protect in a single dose; and practical diagnostic tools were available for the ready 

identification of smallpox infection.

The World Health Organization adopted the goal of eradicating smallpox in 1959, 

but progress was fairly slow until the Intensified Global Eradication program was 

launched in 1967. The strategy was to launch mass vaccination campaigns in each 

country, ensure the potency and stability of the vaccine, and cover at least 80 percent 

of the population. Those campaigns were followed by rigorous disease surveillance 

to detect outbreaks and target them with focused containment measures. Whenever 

an “index” case of smallpox was reported, all close contacts of the index case were 

vaccinated, and then all close contacts of those people would also be vaccinated. This 

method effectively isolated the index case and broke the chain of transmission. 

The last case of smallpox was identified in Somalia in 1977. The search for smallpox cases lasted for another two 

years, and in 1980, the World Health Organization declared that “smallpox is dead!”  

Elizabeth Fee, Ph.D., National Institutes of Health 

Vaccine Milestones: Smallpox Is Dead

This case of smallpox was “made mild” 

by a vaccination, according to the 

caption on this undated photo from the 

U.S. Army Medical Museum.

U.S. National Archives Photos
Global Issues / March 2007 28 eJournal USA

for the next season for each the northern and southern 

hemispheres. 

The Collaborating Centres provide extensive training 

for laboratory staff from National Influenza Centres 

and other laboratories. Every year the centres update 

the standard antigens and sera used by the NICs in the 

network to diagnose seasonal influenza and provide 

advice as needed on the most appropriate and up-to-date 

laboratory methods for the diagnosis of influenza. The 

centres can provide assistance to countries on responding 

to an outbreak of influenza, particularly if it should 

have pandemic potential. They also provide WHO with 

recommendations and guidance on how to improve the 

global system of influenza surveillance.

A New Challenge

Recently the emergence of a new, highly pathogenic 

strain of the influenza virus, H5N1, has raised alarms 

that an influenza pandemic may be imminent, with 

the potential to cause high levels of illness and death 

and widespread social and economic disruption. This 

has presented the surveillance network with significant 

technical and operational challenges that fall beyond its 

established role in detecting and protecting against seasonal 

influenza. 

H5N1 differs substantially from seasonal influenza 

viruses. It is a newly emerging animal virus that is highly 

pathogenic in poultry and has crossed the species barrier 

to infect humans. Handling the virus requires higher 

levels of laboratory containment, and few NICs have the 

necessary experience required to diagnose H5N1 infection 

or to respond to H5N1 outbreaks. As a result, much 

of the heavy workload of the NICs has been falling on 

the Collaborating Centres. In 2004 WHO established 

an ad hoc network, known as the WHO H5 Reference 

Laboratories, to help with diagnosing human H5N1 

infections. This move will allow the Collaborating Centres 

to continue to conduct more advanced analysis of H5N1 

viruses to assess the risk of pandemic and to develop the 

necessary diagnostic reagents (substances used to detect 

or measure H5N1), test protocols, and candidate H5N1 

vaccine viruses. 

In its more than 50-year history, the Global Influenza 

Surveillance Network has played a central role in global 

efforts to address influenza in all of its forms and has 

proven itself to be an exemplary model of international 

cooperation. The partners in this system have established 

technical standards and norms for influenza surveillance 

and diagnosis and have enabled millions of doses of 

vaccines to be produced and administered. While GISN 

continues to protect the world’s population from epidemics 

of seasonal human influenza, it is now also helping 

countries around the world respond to the H5N1 threat 

and prepare for the next influenza pandemic. 

The opinions expressed in this article do not necessarily reflect the views or 

policies of the U.S. government.

The U.S. health care sector goes to great lengths to encourage 

immunization against seasonal flu. Volunteers assisted the Oklahoma 

City-County Health Department in a mass flu immunization exercise 

as the 2006 flu season began. Cars lined up at an immunization drivethrough, allowing the inoculation of more than 1,700 people in a few 

hours. 

© AP Images
29 eJournal USA Global Issues / March 2007

Stanley A. Plotkin, MD, is the executive advisor to the chief 

executive officer of sanofi pasteur, the largest company in the 

world devoted solely to human vaccines. He is an emeritus 

professor of pediatrics at the University of Pennsylvania 

and the developer of the rubella vaccine currently in use, as 

well as codeveloper of the newly licensed rotavirus vaccine. 

Plotkin is senior editor of Vaccines, the standard textbook 

in the field. 

I

t has been often remarked 

that predicting the future is 

fraught with error, and that it 

is much easier to predict the past. 

Nevertheless, I believe certain 

tendencies in the field of vaccine 

development are likely to flourish in 

the near- and long-term future, and 

so I venture to make the following 

10 predictions:

 • The development of combined 

vaccines containing multiple 

valences will increase. Valence is 

the number of different antigens 

in a vaccine—a trivalent vaccine 

has three antigens, for example. An 

antigen is a chemical substance, 

usually a protein that stimulates 

the immune system to produce an 

antibody specific to the antigen. As 

the schedule for early childhood 

vaccination becomes more crowded 

with new vaccines, and as we deal 

with disease syndromes having 

multiple causes, it will be necessary 

to combine vaccines so that 

fewer injections are given. These 

combinations of vaccines will not be simple to develop, as 

the immunologic rules of interference among vaccines are 

not well described.

 • Although many vaccines are administered to infants 

under the age of one year, protection is slow to develop 

because of the immaturity of the immune system. In 

fact, immunity may fade later in childhood if no booster 

doses are given. The specific factors that contribute to the 

immaturity are just becoming known, and I anticipate 

that immunologic adjuvants—substances that enhance 

responses to vaccination—will come into use in infancy.

 • Sexually transmitted diseases, respiratory diseases 

transmitted by crowding, infections 

that cause cancer later in life, 

and infections transmitted from 

mothers to their fetuses all require 

vaccination before adolescence 

begins. Thus, the age of 11 to 

12 years will become a time for 

administration of many newly 

emerging vaccines to provide 

protection during early adult life.

 • The elderly suffer a natural 

aging of the immune system, 

both with respect to antibody 

production and cellular responses 

to infection or vaccination. 

Here again, we are beginning 

to understand the defects that 

come with age, and correction 

of these defects should improve 

the efficacy of vaccines in an 

increasingly aged population.

 • Two new strategies 

have become widespread 

for experimental vaccine 

development: injecting humans 

with DNA segments from 

pathogenic microorganisms that 

produce protective proteins after 

injection, and inserting genes 

from pathogens into harmless 

microorganisms that serve as carriers, or vectors, for 

production of immune responses. Although each strategy 

separately may generate useful vaccines, the combination 

of the two in a so-called “prime-boost sequence” provides 

synergy. Thus, there will be vaccinations consisting of 

Vaccines in the 21st Century

Stanley A. Plotkin

The Iomai Corporation is developing needle-free 

vaccines and immune system stimulants targeting 

influenza and pandemic flu. The director of plant 

operations looks over an automated vaccine patch 

manufacturing machine at company headquarters in 

Gaithersburg, Maryland, near Washington, D.C. 

© AP Images/Charles Dharapak
Global Issues / March 2007 30 eJournal USA

prime-boost regimens, particularly in those cases where 

antibodies are insufficient to give complete protection.

 • Intramuscular or subcutaneous injections have 

served us well as the means to introduce vaccines into 

humans. However, there are limitations to the feasibility of 

numerous injections and theoretical reasons for preferring 

other routes of immunization. Thus, intranasal, aerosol, 

and oral routes of administration are being intensively 

explored for certain vaccines. Moreover, transcutaneous 

immunization using patches, microneedles, and other 

ingenious technologies to pass vaccines through the skin is 

promising. 

 • Malaria, tuberculosis, and HIV are major targets 

of vaccine development. Short-term protection against 

malaria has already been achieved, and I foresee the 

extension of protection by combining several malaria 

antigens in one vaccine, although I suspect that regular 

boosters will be necessary to maintain protection.

 • Prospects for a vaccine that protects against adult 

tuberculosis are good. This will be based on the current 

BCG vaccine. The Bacillus Calmette-Guérin vaccine, 

developed at the Institut Pasteur in Lille, France, in the 

early 20th century, is effective in children but does not 

prevent the infection in adults. Insertion of genes that code 

for additional protective proteins should improve BCG.

 • HIV has proven to be a difficult target for vaccination, 

but a vaccine that reduces the seriousness of infection 

and prolongs life, even while not preventing the disease 

completely, is likely to be the product of current clinical 

trials. The development of a vaccine that prevents infection 

entirely is less likely in the near future.

 • Influenza remains a banal but deadly infection. 

Although the vaccines we have are very beneficial, better 

protection will be derived from the inclusion of more 

influenza proteins, adjuvants, and the combined use of live 

and killed vaccines. 

The opinions expressed in this article do not necessarily reflect the views or 

policies of the U.S. government.
31 eJournal USA Global Issues / March 2007

It is a widely accepted fact that vaccines are among the 

safest and most cost-effective ways available to prevent 

disease and improve the overall level of health in a 

population. That fact balances on two uncertain variables: 

Has science found a vaccine effective against a given 

disease? If so, can that vaccine be delivered to an entire 

vulnerable population? 

Global poverty might 

be significantly reduced 

if the answers to those 

two questions were “yes” 

when it comes to a certain 

class of ancient diseases. 

Neglected tropical diseases 

(NTDs) disproportionately 

affect people of the poorest 

nations, while they are 

almost unheard of in the 

industrialized world. But 

there is a growing recognition 

that an invigorated effort to 

prevent these diseases and 

their resulting disability 

and dysfunction could have 

an enormous impact on 

improving the quality of life 

and alleviating poverty in 

many nations.

Two experts in this 

field discussed these developments with Global Issues

managing editor Charlene Porter. Lee Hall, MD, chief of 

the Parasitology and International Programs Branch at 

the National Institute of Allergy and Infectious Diseases, 

part of the National Institutes of Health, and Peter J. 

Hotez, MD, PhD, Walter G. Ross Professor and Chair of 

Microbiology, Immunology, and Tropical Medicine at the 

George Washington University and Sabin Vaccine Institute, 

have been watching developments in this area of medicine 

and health policy. 

Question: Dr. Hotez, you’ve referred to these diseases as 

the “biblical diseases.” What does that name suggest about 

the long history of these ailments and how severely they 

have plagued the human race? 

Hotez: The “biblical diseases” refer to a set of tropical 

diseases that are sometimes known as the neglected tropical 

diseases. It’s a group of primarily 13 infections that are 

chronic and disabling in their nature, and they occur 

almost exclusively among the world’s poorest people. 

Of the 2.7 billion 

people who live on 

less than $2 a day, 

approximately half 

have one or more of 

these diseases. Their 

common features are 

that they are disabling 

and have huge impacts 

on the growth and 

development of children, 

on pregnancy and 

pregnancy outcome, and 

on worker productivity 

and capacity. Because of 

those features and their 

chronic, disabling nature, 

they’re able to keep the 

poorest populations mired 

in poverty. The diseases 

themselves promote 

poverty.

These are a group of afflictions that have occurred 

in humans since ancient times. You can find vivid 

descriptions of these neglected tropical diseases in ancient 

texts—in the Bible, the Talmud, the Bhagavad-Gita, 

the writings of Hippocrates, Egyptian papyrus. They’re 

sometimes referred to as biblical diseases because of their 

very ancient character.

So when you look at the neglected tropical diseases 

in aggregate, they’re as important as AIDS, they’re 

as important as malaria, and they’re as important as 

tuberculosis. Now we have a great opportunity to do 

something about them in a very substantive way.

Q: Dr. Hall, why is it that there has not been a great 

Ending Disease, Ending Poverty

An Interview With Lee Hall and Peter J. Hotez

Schistosoma mansoni worms cause schistosomiasis. The parasitic, 

microscopic worm found in contaminated water penetrates human 

skin, causing illness that plagues more than 200 million across the 

globe. 

© AP Images/Ric Feld
Global Issues / March 2007 32 eJournal USA

deal of attention paid to the development of vaccines for 

these conditions in the past? And how do you see the 

situation changing?

Hall: There’s been a lot of interest in intervention in 

these diseases for a long time, but it has waxed and waned. 

Back in the early part of the 20th century when there were 

Western military forces deployed in these world regions, 

there was actually a fair amount of interest. Then as those 

military forces were pulled back, interest began to wane. 

Over the past couple of decades, there has been a 

complete change in technology, in biotechnology, and how 

we approach these diseases now. These diseases typically 

are caused by organisms that are much more complex than 

many of the viral and bacterial diseases we usually think 

about. With newer technologies, we’re in a position to 

address the science that underlies many of these diseases 

and start to develop new interventions.

Another key factor that has changed is our recognition 

of the interconnectedness of the globe. The areas where 

these diseases have predominated, as Peter said, were 

impoverished. They did not have the ability to translate 

this unmet medical need into some sort of global 

demand that could be recognized by the pharmaceutical 

industry and capitalized upon in order to produce new 

interventions.

That is now changing, and we realize these diseases are 

a product of poverty and contribute to poverty. As new 

technologies make new tools available, we can actually 

break this cycle of disease by bringing these interventions 

to where they are most needed.

Hotez: One of the great challenges that we 

face now is that our technology has, in some 

sense, raced ahead of our ability to distribute 

products to the people who need them. How 

do you establish a company that’s going to 

make a product for people who can’t afford 

to pay for the product when they live on less 

than $2 a day? You can never expect a forprofit organization that’s responsible to its 

shareholders to take the leadership in making 

these vaccines.

One of the ways that we’ve been working 

to overcome that challenge is to work with 

the National Institutes of Health, work with 

the Bill and Melinda Gates Foundation, to set 

up new nonprofit organizations that are actually 

going to make vaccines. We’re looking at a new 

paradigm where vaccines will not only be made by large 

pharmaceutical companies, but we’ll create a new entity—

sometimes known as PDPs or Product Development 

Partnerships—that’s going to take the lead in making 

vaccines for things like onchocerciasis or schistosomiasis.

That’s going to help revolutionize all the wonderful 

technology that the National Institutes of Health has 

funded over the past two decades. That’s now going to 

be leveraged into manufacturing this new generation of 

products.

Q: The AIDS epidemic also brought greater recognition 

in the donor community about the importance of a 

population’s overall health in overcoming poverty and 

maintaining national security. Isn’t there heightened 

recognition that other tropical diseases also merit attention 

on those grounds?

Hotez: Absolutely. There’s this very fascinating, but 

still not completely well-defined relationship between 

health and security. If you look at the nations of the world 

that have been engaged in conflict over the last 20 years, 

the vast majority of them suffer from neglected tropical 

diseases. 

Think of where the hot spots have been over the last 

two decades. They’ve been places like Somalia, Sierra 

Leone, and Liberia. The common feature is that they 

all suffer from high rates of malaria, neglected tropical 

diseases, and HIV/AIDS. That may be more than just 

coincidence. There may be an opportunity now to use 

health and prevention as a means of reducing conflict and 

reducing tensions in these most devastated nations.

Q: Dr. Hall, let’s explore further the advances in Courtesy Dr. Tom Folks, NIAID

T-cells are a key component of the immune system, and their function is impaired 

when infected with HIV virus, as shown here. 
33 eJournal USA Global Issues / March 2007

biotechnology that are helping you address these diseases. 

Where is the progress being made?

Hall: Let’s start with malaria, for example. We know 

that the three components necessary to maintain the 

parasite’s life cycle are the parasite, the mosquito vector, 

and the human host. We now have completely sequenced 

genomes for all three of them. That allows us to study in a 

much more rigorous way the whole life cycle at a genomic 

and a molecular level. We’re now beginning to achieve that 

same level of scientific knowledge with a number of these 

other diseases.

For example, we now have fully sequenced the genomes 

of the parasites that cause leishmaniasis, Chagas’ disease, 

and African trypanosomiasis. They are all very closely 

related, and yet they have certain distinct features. We 

can do some comparative studies with these now and 

understand better how the parasites actually function and 

what determines their ability to cause disease. There are 

research groups that are sequencing the genome for the 

vectors that transmit some of these parasites like the species 

of fly that transmits human African trypanosomiasis, and 

we’ll soon have that information as well. 

We have already sequenced the human genome and 

understand a variety of biochemical pathways in the 

human host. By comparing genomes and biochemical 

pathways between the parasite and the human host now, 

we hope to be able to identify pathways and targets that 

are unique to the parasite and not shared by the human 

host. Those unique features then allow us to identify 

leads for new drugs, diagnostics, and vaccines. I chose 

three protozoan parasites as examples, but we’re rapidly 

approaching the same situation for diseases caused 

by parasitic worms, such as filariasis [also known as 

elephantiasis] and for schistosomiasis. 

Q: Dr. Hotez, you mentioned the various partnerships 

that are taking shape to help achieve those ends. Explain 

how an increasingly sophisticated pharmaceutical industry 

in the developing world is also contributing. 

Hotez: One of the things that is happening along 

with the Product Development Partnerships is that the 

partnerships will actually include what we call public sector 

vaccine manufacturers in developing countries. I’ll give 

you an example. I head an organization called the Human 

Hookworm Vaccine Initiative, which is part of our Global 

A Nicaraguan boy stands near his mother, who was diagnosed as having leishmaniasis cutaneous, also known as mountain leprosy, during a 2005 

outbreak northeast of Managua. 

© AP Images/Ariel Leon
Global Issues / March 2007 34 eJournal USA

Network for Neglected Tropical Disease Control [http://

www.GNNTDC.org], and the Human Hookworm Vaccine 

Initiative is based at the Sabin Vaccine Institute. It’s a 

Product Development Partnership with the goal of making 

a new recombinant antigen vaccine for human hookworm 

infection, a disease of 576 million people in the developing 

world.

In Washington, D.C., we’ve been able to make pilotscale amounts of vaccine for early-phase clinical testing, 

which is underway in Brazil. The problem is the amount 

we can make in our laboratories through the PDP here 

in Washington is limited, and certainly not enough to 

vaccinate all of Brazil or all of the Americas.

So we’ve now partnered with an organization known 

as Instituto Butantan, which makes 86 percent of the 

vaccines for Brazil, including their own recombinant 

hepatitis B vaccine. So now our scientists are working 

with this public sector vaccine manufacturer in Brazil in a 

collaborative manner. They’re coming up here; we’re going 

down there and transferring our technology so that they 

can do the scale of production for all of the Americas. We 

look forward to the opportunity of working with public 

sector vaccine manufacturers in this group of low-income 

and middle-income countries that also have endemic 

tropical diseases and have great pockets of poverty, and yet 

have somehow managed to overcome their poverty and 

achieve a certain level of innovation that they can actually 

make their own vaccines. We call these types of countries 

IDCs, Innovative Developing Countries, low- and middleincome countries that have gone that next step to take on 

biotechnology and do it in a very sophisticated way.

They include countries such as Brazil, China, Indonesia, 

India, Thailand, and Malaysia, and we think that these 

countries and their public sector vaccine manufacturers 

could lead the way in making a whole new generation of 

products for the developing world.

Q: That trend has been driven to a degree by the AIDS 

epidemic in these countries. Dr. Hall, what are the recent 

findings about the biologic interrelation of these diseases 

with AIDS? 

Hall: There are lots of studies going on to try to define 

that relationship and see how these diseases might affect 

each other, whether HIV makes them worse, whether these 

diseases actually contribute to making HIV worse. We’ve 

not defined that relationship as closely as we would like, 

but our knowledge base in this area is rapidly expanding.

Hotez: Two very exciting papers were published in 

2006 in AIDS, one of the leading HIV/AIDS journals. 

One of them looked at women living in Zimbabwe with 

schistosomiasis, a worm infection, and showed that a large 

percentage of those women—up to 75 percent—have 

lesions resulting from the presence of these parasitic 

The Global Network for Neglected Tropical Disease Control is an alliance of the major public-private 

partnerships devoted to the control of the most prevalent neglected tropical diseases (NTDs) worldwide. The 

Global Network is advancing a plan to control these diseases through the integrated administration of the “rapidimpact package,” so named because the drugs can be quickly deployed with rapid reductions in morbidity and 

disability, improvement in well-being, and, in some cases, interruption of transmission. The package is comprised of 

a combination of up to four drugs, all of which have been in use, tested, deployed and utilized by millions for more 

than a decade. Combining these drugs in an integrated health care package is a new approach that deemphasizes 

specific tropical diseases and, instead, focuses on neglected populations with multiple tropical infections. 

Worldwide, there are a total of 56 countries with five or more endemic NTDs. Most of these are in sub-Saharan 

Africa where the rapid-impact package will be deployed extensively. 

This packaging approach has been successful with early childhood vaccines. By packaging a combination of 

vaccines and inoculating infants against different diseases at the same time, the costs are diminished and the benefits 

are enhanced. 

Identification of the first countries to be included in the Global Network’s rapid-impact treatment scheme is 

currently underway. 

The Global Network is based in Washington, D.C.  

A Quick Strike Against Disease
35 eJournal USA Global Issues / March 2007

worms. As a consequence, they have a threefold increased 

risk of acquiring HIV. 

So what if you could be giving drugs for parasitic worm 

infections at the same time you’re giving antiretroviral 

drugs for HIV/AIDS? The great thing about these parasitic 

worm drugs is they’re cheap, less than 20 cents a dose, 

and could be given to large populations fairly easily. 

That’s why we set up this Global Network for Neglected 

Tropical Disease Control: to find a way to administer 

these antiparasitic drugs to large populations. We think 

treating these worm infections throughout sub-Saharan 

Africa will clearly have a huge benefit in terms of health 

impact because of the diseases that the worms cause, but a 

secondary impact could also result from actually reducing 

the transmission of HIV/AIDS.

By adding an additional 20, 30, 40, or 50 cents to 

the hundreds of dollars spent each year per person on 

antiretrovirals in large AIDS treatment programs such as 

the President’s Emergency Program for AIDS Relief, you 

could possibly double your impact. But the studies are still 

at an early stage.

Q: Dr. Hall, Dr. Hotez has mentioned the drugs that 

can be very cheap and available to treat many of these 

conditions; but why is it that vaccines still seem preferable 

even when drugs would be available?

Hall: There are a number of reasons. First of all, for 

some diseases, it’s going to be very hard to develop vaccines 

even with a great deal of technology. Parasites themselves 

are fantastic immunologists and have actually developed 

ways to escape the immune response, and they’ve been 

doing this longer than we have thought about it, so it’s a 

real challenge.

In other situations, where we can develop vaccines, we 

want to develop them because we would like to prevent 

disease, rather than treat it. The pathology of these diseases 

is really cumulative as it occurs over time, whether it’s 

schistosomiasis or filariasis or some of these other diseases. 

There’s a gradual build up of disease, and treatments of 

an advanced disease aren’t going to necessarily reverse that 

pathology.

We’d like to catch people early on and prevent disease, 

so they don’t develop these diseases.

Hotez: I agree, and at the Global Network, what we think 

is going to be the important way to move forward on 

tropical diseases is not looking at the choice of either drugs 

or vaccines, but in fact, the two need to be linked in a 

tightly coordinated, controlled program. 

Q: To conclude then, is there a single development in 

this field that you think is the most promising for shortterm delivery?

Hall: One has to look at research as a long-term 

endeavor. The pace of research is accelerating as a result 

of success with genome sequencing and a variety of postgenomics activities. That’s really where we’re going to see a 

lot of progress in the near future. 

In addition to that, a number of candidate vaccines have 

already entered clinical development. Peter has mentioned 

the Hookworm Vaccine Initiative. There are also vaccines 

that are in development now for schistosomiasis and for 

leishmaniasis as well. Those are very exciting. 

We’re at a fantastic point in the research where activities 

are moving forward in this area, and they’re beginning to 

accelerate because of the technology.

Hotez: We have a great opportunity now to control 

morbidity [the incidence of disease] from the seven 

most prevalent neglected tropical diseases—ascariasis, 

hookworm, trichiuriasis, schistosomiasis, lymphatic 

filariasis, onchocerciasis, and trachoma—through a 

program of integrated control that employs donated and 

generic drugs. Better controlling those seven diseases 

could make a huge impact on these co-infections that 

occur among the very poorest populations of subSaharan Africa, Southeast Asia, and the Americas. We’re 

going to see dramatic gains in health, education, and 

economic development and, possibly, even biosecurity as a 

consequence of widespread use of these drugs.

One of our projects at the Global Network on NTD 

Control is the distribution of a rapid-impact package of 

drugs. With this package of drugs, which are proven, safe, 

inexpensive treatments for these conditions, we could 

eventually either reduce the morbidity or control the seven 

most prevalent neglected tropical diseases. In addition, for 

two of the NTDs—lymphatic filariasis and trachoma—we 

could even interrupt their transmission and eliminate them 

as public health problems.

So while we’re doing widespread administration of the 

rapid-impact package, we want to step up our research and 

development efforts to focus in on the development of new 

vaccines for the other diseases that we want to eliminate 

—hookworm, schistosomiasis, leishmaniasis, and Buruli 

ulcer—and some of these other very important neglected 

tropical diseases. 

The opinions expressed in this interview do not necessarily reflect the views or 

policies of the U.S. government.
Global Issues / March 2007 36 eJournal USA

Definitions and descriptions of poverty-causing diseases are 

compiled from U.S. and international agencies.

These diseases almost exclusively affect impoverished 

people living in rural areas or poor urban slums of 

low-income countries. They are caused by parasitic 

worms, bacteria, and protozoa. They can be fatal, but 

they primarily cause chronic lifelong disabilities, leading 

to disfigurement, impaired child development, poor 

pregnancy outcomes, and impaired worker productivity. 

Victims of neglected tropical diseases also encounter 

serious stigma in their communities, adding social 

consequences to their health problems. As a result, 

neglected tropical diseases affect the health of poor 

populations, and they mire infected individuals in poverty. 

On national and regional scales, their effects are so dire 

that these diseases are considered conditions that promote 

and perpetuate poverty.

HIV/AIDS, tuberculosis, and malaria are also considered 

by some to be “neglected.” Large-scale funding is now 

being invested in these “big three diseases,” however, 

while no broad initiatives are underway for the 13 major 

parasitic and bacterial infections comprising the neglected 

tropical diseases. Vaccine programs are in early research 

and development for all the neglected tropical diseases 

cited here. 

What Are Neglected Tropical Diseases?

This Colombian soldier shows sores on his arm and face from the disease leishmaniasis. He caught the disease while on patrol in the jungles of 

southern Colombia and received treatment at a base near Bogota.

© AP Images/Zoe Selsky
37 eJournal USA Global Issues / March 2007

Helminth/Intestinal Worm Infections

Hookworm is an intestinal parasitic worm of humans 

that usually causes intestinal blood loss leading to irondeficiency anemia and malnutrition. As a result, heavy 

infection with hookworm can create serious health and 

educational problems for preschool and school-aged 

children, and for women of reproductive age, including 

pregnant women, and for persons with low iron reserves. 

An estimated 600 million people are infected. Recent 

economic estimates indicate that chronic hookworm 

infection in childhood reduces future wage-earning 

capacity by 40 percent.

Onchocerciasis is an infection caused by a parasitic 

worm, which is spread by the bite of an infected blackfly. 

It is also called river blindness because the transmission is 

most intense in remote African rural villages, located near 

streams. Persons with heavy infections will usually have 

dermatitis, eye lesions, and/or subcutaneous nodules. The 

global prevalence is approximately 18 million, of whom 

about 270,000 are blind and another 500,000 have visual 

impairment.

Schistosomiasis, also known 

as bilharzia, is a disease caused 

by parasitic worms found 

in water contaminated with 

human waste. Schistosoma 

parasites can penetrate the skin 

of persons who are wading, 

swimming, bathing, or washing 

in contaminated water. The 

first symptoms are rashes or 

skin irritations, followed later 

by fever, chills, cough, and 

muscle aches. People who are 

repeatedly infected for many 

years may experience damage 

to the liver, intestines, and 

bladder and kidneys. In Africa, 

schistosomiasis is a leading 

cause of chronic renal failure. 

Approximately 200 million 

people are infected worldwide, 

resulting in 280,000 deaths annually.

Protozoan Infections

Amebiasis is a disease caused by a one-celled parasite that 

thrives in unsanitary conditions. The symptoms often are 

quite mild and can include loose stools, stomach pain, 

and stomach cramping. Amebic dysentery is a severe form 

of amebiasis associated with stomach pain, bloody stools, 

and fever. Some patients go on to develop an amebic liver 

abscess. Amebiasis is among the world’s most prevalent 

parasitic illnesses, affecting an estimated 500 million 

people. 

Chagas’ disease is an infection caused by a parasite carried 

by blood-sucking triatomine bugs, which live in cracks and 

holes of substandard housing from the southern United 

States to southern Argentina. Worldwide, it is estimated 

that 16 to 18 million people are infected with Chagas’ 

disease. Of those infected, 50,000 will die each year. For 

about one-third of the persons who get Chagas’ disease, 

chronic symptoms and heart failure develop 10 to 20 years 

after infection. For those who develop chronic symptoms, 

the average life expectancy decreases by an average of nine 

years.

Leishmaniasis is a parasitic disease spread by the bite of 

infected sand flies. The disease may come in a cutaneous 

form, causing skin sores, or in a visceral form affecting 

the internal organs of the body. Skin sores caused 

In Tegucigalpa, Honduras, a city employee fumigates a house during a campaign to kill mosquitoes 

carrying dengue fever. 

© AP Images/Edgard Garrido
Global Issues / March 2007 38 eJournal USA

by leishmaniasis may take months or years to heal if 

untreated. Organ damage resulting from the visceral 

form of the disease can lead to death. This parasite is now 

endemic in 88 countries on five continents—Africa, Asia, 

Europe, North America, and South America—with an 

estimated 12 million people affected worldwide .

Bacterial Infections

Buruli ulcer is a disease caused by infection with 

Mycobacterium ulcerans, which is transmitted to humans 

through an unknown mechanism. Infection causes 

formation of large ulcers usually on the legs or arms, 

leading to extensive destruction of skin and soft tissue. 

Patients who are not treated early often suffer long-term 

disfigurement and functional disability, such as restriction 

of joint movement. Buruli ulcer has been reported in more 

than 30 countries mainly with tropical and subtropical 

climates, but limited knowledge of the disease and its 

occurrence in poor rural communities make global 

estimates of case numbers difficult. 

Chlamydia is the world’s most common sexually 

transmitted disease (STD) and can cause long-term 

damage to a woman’s reproductive organs. Though 

symptoms of chlamydia are usually mild or absent, serious 

complications that cause irreversible damage, including 

infertility, can occur unnoticed before a woman ever 

recognizes a problem. Chlamydia also can cause discharge 

from an infected man and pain and itching in urination. 

Complications among men are rare. Another important 

form of human chlamydia infection is known as trachoma, 

which is nonsexually transmitted and results in visual 

impairment or even blindness. It is the most common 

infectious cause of blindness in the world. Currently, 

8 million people are visually impaired as a result of 

trachoma, and 84 million suffer from active infection.

Leprosy is a bacterial disease with an incubation period 

of about five years. Symptoms can take as long as 20 years 

to appear. It is transmitted through close contact with 

untreated cases via droplets from the nose and mouth. 

Leprosy mainly affects the skin and nerves. If untreated, 

This banner displayed in Singapore is part of a multimillion dollar government effort to promote preventive measures against the breeding of 

mosquitoes that spread dengue fever.

 © AP Images/Wong May
39 eJournal USA Global Issues / March 2007

progressive and permanent damage to the skin, nerves, 

limbs, and eyes may result. Leprosy is a curable disease, 

and treatment provided in the early stages averts disability. 

The global occurrence has dropped dramatically from 

more than 5 million annual cases in 1985 to fewer than 

300,000 in 2004.

Leptospirosis is a bacterial disease that affects both 

humans and animals. The early stages of the disease may 

include high fever, severe headache, muscle pain, chills, 

redness in the eyes, abdominal pain, jaundice, hemorrhages 

in skin and mucous membranes, vomiting, diarrhea, and a 

rash. Human infection occurs through direct contact with 

the urine of infected animals or by contact with a urinecontaminated environment, such as surface water, soil, and 

plants. Because the symptoms are similar to other diseases, 

leptospirosis is often not recognized, and a precise number 

of cases worldwide is not known. 

Treponematoses encompass a group of diseases caused by 

one of several different strains of the spirochete bacterium. 

The group includes yaws, a disease of the skin, bones, and 

joints passed from one person to another through bacteria 

carried by eye gnats or entrance of the bacteria through a 

cut. Bejel, or endemic syphilis, is a chronic skin and tissue 

disease caused by a related strain of bacteria, producing 

lesions on the limbs and trunk and inflammation of the leg 

bones. Pinta is another condition in this family of diseases, 

and it also produces skin lesions. The several strains are 

distinct to different world regions, and they usually can be 

treated with antibiotics. Together the diseases affect about 

25 million people.

Viral Infections

Dengue is a mosquito-borne infection found in tropical 

and subtropical regions around the world. Dengue fever is 

a severe, flu-like illness that affects infants, young children, 

and adults, but seldom causes death. Dengue hemorrhagic 

fever (DHF) is a potentially lethal complication, 

characterized by high fever, hemorrhagic phenomena—

often with enlargement of the liver—and in severe cases, 

circulatory failure. WHO currently estimates there may be 

50 million cases of dengue infection worldwide every year.

Japanese encephalitis is a disease caused by a virus 

transmitted to humans through a mosquito bite. 

Mosquitoes pick up the virus from feeding on domestic 

pigs and wild birds. Mild infections occur without 

apparent symptoms other than fever with headache. More 

severe infection is marked by quick onset, headache, high 

fever, neck stiffness, stupor, disorientation, coma, tremors, 

occasional convulsions, and spastic paralysis. Japanese 

encephalitis is the leading cause of viral encephalitis in Asia 

with 30,000 to 50,000 cases reported annually. 

Sources: International Leptospirosis Society; International Trachoma 

Initiative; U.S. Centers for Disease Control and Prevention; University of 

California, Berkeley; World Health Organization; the Global Network for 

Neglected Tropical Disease Control. 
Global Issues / March 2007 40 eJournal USA

Vaccines must be held to a very high standard of safety. 

Stringent measures are taken to ensure quality and safety 

in the research and development, manufacturing, licensing, 

transport, storage, and use of vaccines, and in the disposal 

of needles and other equipment after vaccinations are 

carried out.

Research and Development

Like other pharmaceutical products, vaccines are first 

carefully evaluated for effectiveness and potential 

harmful effects in vitro [in an artificial environment] 

and in animals. If good safety results are achieved, phased 

trials with humans begin.

Phase I clinical trials examine safety and immune 

responses to candidate vaccines. Such trials generally have 

20 or fewer participants, usually healthy adults. These trials 

are meant to identify any obvious or commonly occurring 

adverse reactions. Phase II trials, which may have from 

50 to several hundred participants, help researchers to 

determine the optimum vaccine composition for achieving 

protection while ensuring safety.

Phase III trials are designed to see if a vaccine actually 

prevents a disease as intended, and to provide further 

safety information. They serve as the final gatekeepers 

prior to vaccines’ introduction for wider use in the general 

population. Phase III trials involve thousands to tens of 

thousands of people of the intended age. In general, Phase 

Ensuring the Quality and Safety of Vaccines 

World Health Organization Fact Sheet

(Excerpted)

At their production facility in France, sanofi pasteur technicians culture the viruses that will be used in an inactivated—or killed—polio vaccine.

Photo courtesy sanofi pasteur
41 eJournal USA Global Issues / March 2007

III trials include a control group receiving a placebo. 

Subsequent adverse events (or medical incidents that may 

or may not be the result of vaccination) and the rates of 

occurrence of target diseases are compared between the 

groups of vaccinated and unvaccinated persons. Should 

significant safety issues arise during a human trial at any 

phase, mechanisms are in place to stop the study and stop 

administration of the vaccine. If there are significant safety 

concerns, the vaccine does not go forward for licensing.

Safety Monitoring of Licensed Vaccines

Once vaccines are licensed for general use and are 

administered to large populations, monitoring continues 

to identify less common adverse events, events that may 

occur after a long time, or events that may occur in specific 

subgroups of the target population.

Typically, monitoring of licensed vaccines is done 

through spontaneous reporting systems, whereby adverse 

events that follow immunization are reported to health 

authorities. Sometimes post-licensing monitoring is 

conducted in more formal Phase IV trials.

Detection of an adverse event following immunization 

does not necessarily mean the event was caused by the 

vaccine. Determination of a cause-and-effect relationship 

requires further investigation.

Manufacturing

Numerous regulations ensure the safety and quality 

of vaccines. They include the precise identification 

(characterization) of starting materials, compliance with 

the principles of good manufacturing practices, the use of 

detailed control procedures, and the independent release 

of vaccines on a lot-by-lot basis by national regulatory 

authorities. Responsibility for quality and safety rests with 

the national regulatory authority (NRA) in the country of 

manufacture and, where exported, with the NRAs of the 

receiving countries.

The World Health Organization (WHO) helps 

strengthen the regulatory capacities of NRAs through 

periodic assessments against a published set of indicators. 

WHO also provides technical support to NRAs where 

appropriate.

Vaccine Transportation and Storage

Vaccines must constantly be kept at optimal 

temperature, typically at between 2 degrees and 8 degrees 

Celsius, from the place of manufacture to the point of 

use. This is a logistical challenge, especially in developing 

countries. The network set up to ensure that the required 

temperature is maintained is called the “cold chain.” 

Refrigerators, ice packs, and cold boxes are employed on 

airplanes, helicopters, and trucks, and in various storage 

locations; in areas not reached by road, chilled vaccine 

carriers are transported by hand to reach the point of use.

If electricity is not available, gas, kerosene, or even 

solar-powered refrigerators or freezers may be used. Most 

refrigerators and related equipment can be selected to 

meet WHO-UNICEF Performance Quality and Safety 

standards. Staff at international, national, and local levels 

are trained to manage cold chain networks. They include 

technicians, shippers, customs officers, pilots, drivers, 

government officials, health workers, and community 

leaders. Among other things, they monitor the temperature 

of the vaccines and discard those that have exceeded the 

established limits.

Vaccine vial monitors (VVMs)—temperature-sensitive 

labels—can be attached to vaccine vials and indicate 

through a change in color whether an individual vial 

has been exposed to heat that is likely to have damaged 

the vaccine. These labels have been successfully used to 

monitor vaccines taken beyond well-established cold 

chain settings, such as clinics, to field sites used for mass 

immunization campaigns. In these latter settings, which 

may be remote and without any access to refrigeration, the 

vaccines need to be kept in containers with cold packs. The 

VVM vial labels enable health care providers to determine 

at a glance if a vial has been kept within the needed 

temperature range or not.

Safe Injections

Many vaccines are delivered by injection. WHO 

promotes safe injection practices as a priority. Vaccinerelated injections are safe for the recipient when a health 

worker uses a sterile syringe, a sterile needle, and a sterile 

technique for each injection. They are safe for health 

workers when needle-stick injuries are avoided. They 

are safe for the community when used needles, injection 

equipment, and vaccine waste are disposed of in such a 
Global Issues / March 2007 42 eJournal USA

way as to avoid injuries from potentially contaminated 

needles and to minimize pollution.

For immunization, WHO recommends the exclusive 

use of syringes with auto-disable features that prevent 

reuse; these are now available, inexpensive, and widely 

employed. In addition, WHO recommends the immediate 

disposal of used needles and syringes into punctureresistant safety boxes, a practice fast becoming the standard 

around the world. Equipment and safety procedures 

continue to be improved.

The General Risks of Vaccines

No vaccine is perfect—that is, no vaccine provides full 

protection against its target disease for every person who 

receives it, and no vaccine is completely risk-free for every 

person who receives it. Experience has shown that most 

adverse events are not actually caused by vaccines; the 

majority are coincidental (occur at the same time but are 

not related), while others are related to preventable errors 

in the storage, handling, or administration of vaccines.

While vaccines can cause reactions, these tend to be 

minor, such as a sore arm, redness or minor swelling at the 

injection site, or low-grade fever. Extremely rarely, there 

are more serious consequences. For example, anaphylaxis 

(immediate, severe allergic reaction leading to shock) has 

been noted at a rate of one per 1 million persons receiving 

measles vaccine, and vaccine-associated paralytic polio 

occurs in approximately one in 2.5 million Oral Polio 

Vaccine (OPV) doses administered. The risk of these more 

serious reactions must always be weighed against the major 

benefits of protecting large numbers of people against 

serious and even life-threatening diseases.

Periodically, concerns about vaccine safety are raised 

that later prove to be unfounded. For example, there is 

no valid evidence of a causal link between measles vaccine 

and autism, a topic that has been extensively reviewed by 

the Global Advisory Committee on Vaccine Safety and 

several other expert bodies. Similarly, no valid evidence has 

been found to support an alleged link between whole-cell 

pertussis vaccine and brain damage, or hepatitis B vaccine 

and leukemia or multiple sclerosis. 

Copyright © World Health Organization 2005. All rights reserved.

The opinions expressed in this article do not necessarily reflect the views or 

policies of the U.S. government.
43 eJournal USA Global Issues / March 2007

In developed countries where routine childhood 

immunization has been in place for decades, some diseases 

have virtually disappeared, and the memories of their fatal 

or disabling consequences have been forgotten. Most parents 

in the developed world have never seen a child paralyzed by 

polio or brain-damaged by measles. As a result, fear of these 

diseases does not haunt parents as it once did.

At the same time, widely broadcast news stories about 

pharmaceutical recalls and drug tampering episodes 

have heightened public concerns about product safety 

and the reliability of recommendations from the medical 

establishment. That climate has 

contributed to resistance among 

some parents to the regimen of 

immunizations recommended 

by government agencies and 

medical professionals. The 

Internet has provided a forum 

in which these fears are further 

heightened by the rapid 

transmission of information, 

which is sometimes misleading 

or inaccurate. 

Many governmental, 

international, and professional 

organizations are responding 

to the concerns about vaccines. 

The National Network for 

Immunization Information, 

for example, offers parents this 

advice about vaccines. 

Vaccine Safety and Risk Perception

No vaccine is 100 percent effective; no vaccine is 

100 percent safe. As with any drug, there are risks 

and side effects with vaccines, although serious 

side effects are mostly rare. However, there is a much 

higher standard of safety expected of preventive vaccines 

than for drugs because: 

• Vaccines are generally given to many people, most 

of whom are healthy. People tolerate far less risk 

from Haemophilus influenzae type b vaccines than 

the antibiotics used to treat the diseases it causes, for 

example. 

• Many vaccines are given to children at the ages 

when developmental and other problems are 

being recognized for the first time. Because a 

developmental problem was spotted at about the 

same time as immunizations were received does not 

mean that one caused the other. 

• Some vaccines are mandated by law in order to 

protect the health and welfare of the public. Some 

people think that this violates their civil rights. 

Research shows that 

people respond better to 

some types of risks than 

others. 

Natural risks (such as 

infectious diseases) are better 

tolerated than man-made 

risks (such as vaccine side 

effects). Also, risks that affect 

adults are better tolerated 

than risks affecting children. 

Risks that are perceived with 

unclear benefits may be less 

tolerated than risks where 

the benefits are understood. 

Take, for example, 

measles and the MMR 

(measles-mumps-rubella) 

vaccine. Since these diseases 

are no longer epidemic in 

developed countries, some 

parents incorrectly assume that the risk of contracting the 

disease is lower than the risk of their child experiencing 

an adverse reaction to MMR. They conclude that there 

may be little benefit from immunizing their child, hence 

there may seem to be no reason to take the risk of an 

adverse event. However, there was a mumps outbreak in 

the United States in 2006, probably introduced from the 

epidemic in Great Britain. These infections are just a plane 

ride away. 

Perception of risk depends on people’s experiences and 

knowledge. A person who experienced an adverse event 

Concerns About Vaccine Safety

The homepage of www.immunizationinfo.org. The National 

Network for Immunization Information (NNii) is affiliated with a 

broad range of respected medical societies and provides the public 

with current, scientifically valid information related to immunization. 
Global Issues / March 2007 44 eJournal USA

after vaccination—or thinks that they know someone 

who did—will perceive vaccines as riskier than a person 

who has not. Conversely, one who has survived a vaccinepreventable disease—or a physician who has treated that 

disease—will likely be an advocate for vaccines. 

Although concerns about vaccine safety are valid and 

necessary we must carefully examine each claim about the 

risks of immunizations: 

• Is the claim relying on scientific data (for example, 

large, controlled studies published in respected 

scientific journals) or on anecdotes (personal stories 

of sick persons)? 

• Are the claims based on facts or are they personal 

opinions? 

Missing Information

When up-to-date, complete, and scientifically valid 

information about vaccines 

is available, parents can make 

informed decisions. Without this 

information many may develop a 

false sense of security and regard 

immunizations as unimportant. 

Unfortunately, when a 

community has low immunization 

rates, many children, including 

some who have been immunized, 

are placed at risk of harm if a 

highly communicable disease like measles is introduced 

into the community. With global travel an everyday 

occurrence, measles may be introduced from another 

country at any time, posing a threat to communities with 

low immunization rates. For instance, in March 2004, 

the U.S. Centers for Disease Control and Prevention 

(CDC) published information about a student flying 

from India to Cedar Rapids, Iowa, while incubating 

measles, as well as cases of measles among children who 

had recently been adopted from China (see CDC’s 

report at http://www.cdc.gov/mmwr/preview/mmwrhtml/

mm53d319a1.htm). 

Like parents, scientists and scientific review groups need 

data to evaluate vaccine safety concerns. Vaccine safety 

research often requires very large and often expensive 

studies that have not been conducted. So when a vaccine 

safety concern is suggested, the necessary data to support 

or reject the hypothesis may not yet have been collected—

in fact sometimes this may take several years of research. 

This often leaves scientific review groups like the Institute 

of Medicine (IOM) Vaccine Safety Committee with 

insufficient data to be able to fully evaluate vaccine safety 

concerns. 

Another example of missing information arose 

from a case concerning the hypothesis that the use of 

thimerosal, a mercury-containing preservative, in vaccines 

caused autism. This idea was first suggested in 1999, 

and the ensuing controversy demonstrates the dilemma 

of insufficient data. In 2001, when the Institute of 

Medicine’s Immunization Safety Review Committee first 

examined the issue, it stated that the available evidence was 

inadequate to decide. In other words, the information was 

missing. By 2004, however, much more scientific data was 

available, and the IOM committee was able to conclude 

that the data favored rejection of a link between vaccines 

and autism.

Misinformation

Some vaccine safety concerns 

persist despite the evidence against 

them. Even when the concern is 

resolved for most in the scientific 

community, suspicions about safety 

may remain an issue for others with 

vested interests, such as lawyers, 

journalists, or well-intentioned but 

misinformed parents. 

In spite of the substantial evidence now available that 

allows rejection of the hypothesis that vaccines cause 

autism, there are some who continue to state that there is 

a causal association. These claims, once based on missing 

information, now fall into the category of misinformation. 

Unfortunately, the misinformed person with a fixed 

opinion about vaccines has many sophisticated tools to 

disseminate misinformation, creating confusion about 

vaccine safety. Misinformation comes in many packages 

and may be widely publicized by the media and others 

causing lowered immunization levels and heightened 

disease risk. 

Misinformation about vaccines is frequently 

encountered on the Internet. Some Web sites, for instance, 

oppose the immunization of infants and children. They 

express a variety of claims that are largely unsupported by 

peer-reviewed scientific literature.

Some vaccine safety 

concerns persist despite 

the evidence against 

them.
45 eJournal USA Global Issues / March 2007

Misinformation Web sites tend to ignore or distort 

scientific studies, instead relying on emotionally filled 

anecdotes about bad things that happened to children or 

coincided in time with vaccine administration. 

Unfortunately for communities, antivaccination 

movements have also had a negative effect on public health 

through the years. One study published in The Lancet

in 1998 showed that movements against the whooping 

cough vaccine caused whooping cough epidemics in several 

countries. 

Adapted by Global Issues with permission, from an article 

by Martin G. Myers and Diego Pineda (2007) “Vaccine 

Misinformation” © National Network for Immunization 

Information. The original is available at

http://www.immunizationinfo.org/immunization_issues_

detail.cfv?id=52.

NNii is affiliated with the Infectious Diseases Society 

of America, the Pediatric Infectious Diseases Society, the 

American Academy of Pediatrics, the American Nurses 

Association, the American Academy of Family Physicians, 

the National Association of Pediatric Nurse Practitioners, the 

American College of Obstetricians and Gynecologists, and the 

American Medical Association.

The opinions expressed in this article do not necessarily reflect the views or 

policies of the U.S. government.

Video Online

• Vaccines: Separating Facts from Fear

The Vaccine Education Center of the Children’s 

Hospital of Philadelphia (CHOP) has produced an 

online video, Vaccines: Separating Facts from Fear. In 

this excerpt (used with permission), CHOP’s Dr. Paul 

Offit, chief of the Division of Infectious Diseases and 

director of the Vaccine Education Center, talks to 

parents about their concerns as other physicians and 

parents recount their experiences.

http://usinfo.state.gov/journals/itgic/0307/ijge/ijge0307.htm
Global Issues / March 2007 46 eJournal USA

AIDS Vaccine Advocacy Coalition. AIDS Vaccines: The 

Next Frontiers. New York: The Coalition, 2006.

http://www.avac.org/pdf/reports/2006_Report/AVAC_Report_

2006_single.pdf

Allen, Arthur. Vaccine: The Controversial Story of Medicine’s 

Greatest Lifesaver. New York: W.W. Norton, 2007.

Bilous, Julian, et al. “A New Global Immunisation Vision 

and Strategy.” The Lancet, vol. 367, no. 9521 (May 6, 

2006): pp. 1464-1466.

Dugger, Celia W. “Mothers of Nepal Vanquish a Killer of 

Children [measles].” The New York Times (April 30, 2006): 

p. 1.

Dugger, Celia W., and Donald G. McNeil, Jr. “Rumor, 

Fear and Fatigue Hinder Final Push to End Polio.” The 

New York Times (March 20, 2006): p. 1.

Hotez, Peter J. “The ‘Biblical Diseases’ and U.S. Vaccine 

Diplomacy.” Brown Journal of World Affairs, vol. 12, no. 2 

(Winter 2005/Spring 2006): pp. 247-258.

Hotez, Peter J., and Meghan T. Ferris. “The Antipoverty 

Vaccines.” Vaccine, vol. 24, no. 31/32 (July 2006): pp. 

5787-5799.

Hotez, Peter J., et al. “Incorporating a Rapid-Impact 

Package for Neglected Tropical Diseases with Programs for 

HIV/AIDS, Tuberculosis, and Malaria: A Comprehensive 

Pro-Poor Health Policy and Strategy for the Developing 

World.” PLoS Medicine, vol. 3, no. 5 (May 2006): pp. 576-

584.

Houlton, Sarah. “A Jab to Beat Cancer?” Manufacturing 

Chemist, vol. 77, no. 9 (September 2006): pp. 59-62.

Kahn, Patricia, ed. AIDS Vaccine Handbook. New York: 

AIDS Vaccine Advocacy Coalition, 2nd edition, 2005.

http://www.avac.org/handbook.htm

Leahy, Michael. “Breaking the Cycle [malaria].” The 

Washington Post Magazine (October 8, 2006): pp. 16-23, 

31-36.

Plotkin, Stanley A. “Vaccines: Past, Present and Future.” 

Nature Medicine, vol. 11 Supplement (April 2005): pp. 5-

11.

Plotkin, Stanley A. “Why Certain Vaccines Have Been 

Delayed or Not Developed at All.” Health Affairs, vol. 24, 

no. 3 (May/June 2005): pp. 631-635.

Seytre, Bernard, and Mary Shaffer. The Death of a Disease:

A History of the Eradication of Poliomyelitis. Piscataway, NJ: 

Rutgers University Press, 2005.

U.S. Agency for International Development. Immunization 

Essentials: A Practical Field Guide. Washington, D.C.: 

USAID, 2003.

http://pdf.usaid.gov/pdf_docs/PNACU960.pdf

Wardlaw, Tessa, et al. “Pneumonia: The Leading Killer of 

Children.” The Lancet, vol. 368, no. 9541 (September 23, 

2006): pp. 1048-1050.

Wechsler, Jill. “New Research Models Spur Third-World 

Efforts.” Applied Clinical Trials, vol. 15, no. 9 (September 

2006): pp. 22-26.

Wolfson, Lara J., et al. “Has the 2005 Measles Mortality 

Reduction Goal Been Achieved? A Natural History 

Modelling Study,” The Lancet, vol. 369, no. 9557 (January 

20, 2007): pp. 191-200. 

World Health Organization. Immunization in Practice:

A Practical Resource Guide for Health Workers. Geneva: 

WHO, 2004.

http://www.who.int/vaccines-documents/DoxTrng/h4iip.htm

World Health Organization and UNICEF. Global 

Immunization Vision and Strategy 2006-2015. Geneva and 

New York: WHO and UNICEF, 2005.

http://www.who.int/vaccines-documents/DocsPDF05/GIVS_

Final_EN.pdf

The U.S. Department of State assumes no responsibility for the content and 

availability of the resources from other agencies and organizations listed 

above. All Internet links were active as of March 2007.

Bibliography

Readings on vaccines, research, and routine immunization programs
47 eJournal USA Global Issues / March 2007

U.S. GOVERNMENT RESOURCES

Centers for Disease Control and Prevention (CDC)

National Immunization Project

http://www.cdc.gov/nip/default.htm

Department of Health and Human Services

National Vaccine Program Office

http://www.hhs.gov/nvpo/

Food and Drug Administration

Center for Biologics Evaluation and Research

http://www.fda.gov/cber/vaccines.htm

National Institutes of Health

Vaccine Research Center

http://www.vrc.nih.gov/VRC/

U.S. Agency for International Development

Immunization Basics

http://www.immunizationbasics.jsi.com/

INTERNATIONAL ORGANIZATIONS

Global Alliance for Vaccines and Immunizations

http://www.gavialliance.org/

Pan American Health Organization

Immunization

http://www.paho.org/english/ad/fch/im/Vaccines.htm

World Health Organization

Expanded Programme on Immunization

http://www.wpro.who.int/sites/epi/overview.htm

World Health Organization

Immunizations, Vaccines and Biologicals

http://www.who.int/immunization/en/index.html

CHILDHOOD VACCINATIONS

Childhood Immunization Support Program

http://www.cispimmunize.org/

The Childhood Immunization Support Program, 

supported by the American Academy of Pediatrics, offers 

information on immunization for parents. 

PATH

http://www.path.org/vaccineresources

PATH is an international, nonprofit organization working 

toward sustainable, culturally relevant solutions to enable 

communities worldwide to break longstanding cycles of 

poor health. 

Vaccine Education Center

http://www.chop.edu/consumer/jsp/microsite/

microsite.jsp?id=75918

The Children’s Hospital of Philadelphia, Pennsylvania, 

sponsors this site devoted to dispelling misconceptions and 

misinformation surrounding childhood vaccines.

DISEASE VACCINE INITIATIVES

Aeras Global Tuberculosis Vaccine Foundation

http://www.aeras.org/

Aeras works to develop new vaccines against tuberculosis 

and ensure availability to all who need them. A nonprofit 

organization, Aeras receives support from the Bill 

& Melinda Gates Foundation, the U.S. Centers for 

Disease Control and Prevention, and the Government of 

Denmark. 

AIDS Vaccine Advocacy Coalition

http://www.avac.org

Founded in 1995, the nonprofit AIDS Vaccine Advocacy 

Coalition (AVAC) seeks to promote accelerated research 

and global delivery of AIDS vaccines.

Internet Resources

Online resources about vaccines, research, and routine immunization programs
Global Issues / March 2007 48 eJournal USA

Center for HIV-AIDS Vaccine Immunology

http://chavi.org/

The Center for HIV-AIDS Vaccine Immunology (CHAVI) 

is a consortium of universities and academic medical 

centers established by the National Institute of Allergy 

and Infectious Diseases to solve problems in HIV vaccine 

development and design.

Global Polio Eradication Initiative

http://www.polioeradication.org/

International AIDS Vaccine Initiative

http://www.iavi.org

The International AIDS Vaccine Initiative (IAVI) is a 

nonprofit organization operating in 23 countries and 

working to speed the search for a vaccine to prevent HIV 

infection and AIDS.

Malaria Vaccine Initiative

http://malariavaccine.org

The mission of the Malaria Vaccine Initiative (MVI) is to 

accelerate the development of promising malaria vaccine 

and to ensure its availability and accessibility in the 

developing world.

Smithsonian Institution

Whatever Happened to Polio?

http://americanhistory.si.edu/polio/index.htm

Tuberculosis Vaccine Fact Sheet

http://www.cdc.gov/nchstp/tb/pubs/tbfactsheets/250120.htm

RESOURCES FOR HEALTH PROFESSIONALS

Allied Vaccine Group

http://www.vaccine.org/

This site is a portal dedicated to presenting scientific 

information about vaccines.

Immunization Action Coalition

http://www.immunize.org/

http://www.immunize.org/catg.d/noneng.htm

The Immunization Action Coalition works to increase 

immunization rates and prevent disease by creating and 

distributing educational materials for health professionals 

and the public.

National Foundation for Infectious Diseases

http://www.nfid.org/index.html

The National Foundation for Infectious Diseases is a 

nonprofit group working to educate the public and 

healthcare professionals about the causes, treatment, and 

prevention of infectious diseases.

National Network for Immunization Information

http://www.immunizationinfo.org/

The National Network for Immunization Information 

(NNii) works to provide scientifically valid information 

related to immunization. NNii is an affiliation of the 

Infectious Diseases Society of America, the Pediatric 

Infectious Diseases Society, the American Academy of 

Pediatrics, and other related associations. 

The U.S. Department of State assumes no responsibility for the content and 

availability of the resources from other agencies and organizations listed 

above. All Internet links were active as of March 2007.