More children are now immunized across the globe than ever before, according to the 2009 The State of the World's Vaccines and Immunization Report, released Wednesday. An estimated 106 million infants received vaccinations in 2008, noted the analysis published by the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and The World Bank.

"This represents more than 2.5 million deaths prevented," Jon Andrus, deputy director of the Pan American Health Organization (PAHO), said at a press briefing about the results. "Is that enough? No." Some 24 million infants worldwide still do not receive all of the recommended inoculations in their first year.

The Global Immunization Vision and Strategy (GIVS), co-sponsored by WHO and UNICEF, estimates that by vaccinating 90 percent of the world's children against 14 illnesses for which there are vaccines (diphtheria, pertussis, tetanus, measles, polio, tuberculosis, hepatitis B, Hib disease, rubella, meningococcal disease, pneumococcal disease, rotavirus, and, where applicable, Japanese encephalitis and yellow fever), another two million child deaths could be prevented. If achieved, that number would go a long way toward meeting the goals of the 2000 United Nations Millennium Declaration, which sought to decrease mortality in children under five by two thirds by 2015 (using 1990 figures as a basis).

"This is about saving lives," Daisy Mafubelu, WHO assistant director general of Family and Community Health, said at the briefing. But saving lives does not come cheaply. Reaching the GIVS goals would cost about $76 billion, as the cost of immunizing each child is on the rise.

Cost of saving lives
In the 1980s immunizing each child cost only a few dollars on average. But by next year it is expected to run about $18. To meet the GIVS target, that figure would increase to $30, due to the sheer number of vaccines required and the complexity of newer formulas. Such per-child costs may not sound like much in today's expensive U.S. health care market, but for many developing countries, that is more than 10 percent of annual per capita income.

Much of the tab is picked up by governments, although international aid organizations, such as UNICEF, are currently buying more than half of the vaccines that go to children.

All the money also adds up to a mammoth industry. Having burgeoned to nearly three times its 2000 size, the global market for vaccines was more than $17 billion last year. As vaccine and immunization programs expand and become more stable, more drugmakers are inclined to get into the market. "With bigger volume—and bigger predictable volume—we're getting more manufacturers entering," Helen Evans, deputy chief executive officer of the Global Alliance for Vaccines and Immunizations, said at the meeting. And the growing amount of competition has helped to drive down the price of individual vaccines.

The substantial costs can be recouped in the long run by savings on subsequent reduced medical treatment for the illnesses. The cost of vaccinating against smallpox across the globe between 1967 and 1977 cost about $100 million. The eradication of the disease, however, has saved an estimated $1.3 billion a year since then, according to the report.

"Immunization does not only save lives, it improves them," Saad Houry, deputy executive director of UNICEF, said at the briefing. It can also improve the health of a nation's economy. Even those who survive preventable childhood illnesses are often either physically disabled or less educated (due to missed school) and are unable to contribute as much to the economy as healthier individuals.

Reaching more people
A hobbled international economy will certainly put new strains on expensive international vaccination programs, although the recession has not impacted UNICEF's funding for vaccines, and many countries have continued to support purchases despite declining GDPs, Houry said. An increase in overall poverty, however, will likely mean fewer children are immunized. "Of [the] 89 million people who will be pushed back into poverty" by the global recession, Rakesh Nangia, The World Bank Institute'svice president and director of strategy and operations for the bank's Human Development Network, said at the briefing, "many of the children will not be able to get their vaccines."

Promising new vaccines also present new challenges. Those meant for adolescents, such as the human papillomavirus (HPV) vaccine, or for adults, such as the H1N1 vaccine, will need new tactics for distribution. Public health workers in the field hope to capitalize on existing distribution channels to reach some recipients—as they already do for distributing other preventative tools such as vitamin supplements and mosquito bed nets—but more strategizing remains.

The last 20 percent of the population not receiving the inoculations will be the hardest to reach, UNICEF's Houry noted. That fifth also usually includes those who don't receive other health or basic services, a sign of deeper inequity. Just physically getting vaccines to many rural populations can present incredible logistical challenges, especially in tropical climates where continuous refrigeration of vaccine courses is especially difficult. "In many cases the systems of delivery are very weak," Nangia said.

In some areas suspicion about vaccines in general can provide another distribution roadblock, the report authors concluded. And long-term global changes, including climate change and the emergence of novel diseases, ensure the battle to eradicate preventable diseases will not be easily—if ever—fully won. The report authors noted, for example: "Climate change looms large and is likely to alter the epidemiological landscape in which vaccines and immunization operate—bringing new health challenges."

Despite the note of victory in many of the voices of those who have worked long years to reach the 100-million-immunization mark, a tone of caution presided. Approximately 10 million children still die every year—many of those from preventable diseases that are contracted due to lack of access to clean water or existing vaccines. For example, pneumonia and diarrhea, together, account for more than a third of deaths in children younger than five years, the report noted. And the inequality between those who die from these illnesses and those for whom they are a minor, treatable malady, points to broader societal issues, many of the experts asserted.

"The topic of health must be included in any policy dialogue," PAHO's Andrus said at the briefing. Others involved in the work agreed that, indeed, global health was a key element to overcoming many other international challenges. "We see health as a bridge to peace," added Stephen Blount, director of the Coordinating Office for Global Health at the U.S. Centers for Disease Control and Prevention.