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Introduction The role of preventive medicine in keeping society healthy has been recognised from ancient times.1 In the last two centuries, the vaccination has been one of the most noticeable and impactful preventive medicine interventions, since the time smallpox vaccination became available.2 In the last century, with the availability of many vaccines which successfully reduced the disease burden, the global community collectively committed to the mission of preventing and reducing the global burden of vaccine-preventable diseases. For its realisation, the Expanded Programme on Immunization (EPI) was established in 1974 to develop and expand immunisation coverage worldwide.3 The global call for EPI was followed by countries adopting the vaccination under various names such as EPI in India in 1978, which was renamed as Universal Immunization Program in 1985.2 However, years before EPI, smallpox and influenza vaccines were considered to save many lives, all over the world. The success of smallpox eradication efforts boosted the vaccination programme and gave a new direction to the whole world, particularly to EPI itself. Goals for EPI were inter alia-to make vaccination against pertussis, diphtheria, tetanus, poliomyelitis, measles and tuberculosis available to all children by 1990 and to optimally utilise vaccination infrastructure created during the smallpox eradication period. EPI aimed at reduction of morbidity and mortality due to vaccine-preventable diseases. In the course of implementation, the programme encountered several roadblocks arising due to a lack of government and public awareness of these target diseases, inadequate equipment and skills regarding vaccine storage and handling, ineffective programme management and lacking programme impact monitoring. The EPI was a key component in providing Health for All by the year 2000.4 Global Scenario of Vaccination During 1974–1990 The vaccination programme are to be more effective, if done at the appropriate age. The immunisation schedule proposed by World Health Organization (WHO) in EPI emphasized on vaccination of all infants with Bacillus Calmette–Guerin dose, 3 doses of Diphtheria, Pertussis, Tetanus (DPT) and polio along with one dose of measles before completing the first birthday. Then, booster dose of Diphtheria and Tetanus (DT) and two doses of typhoid were added for school entrants.3,4 Initially, in 1974, <5% of children received the three doses of DPT and polio in 1st year of life. In developing countries, this coverage surpassed 50% in 1987 and over 700,000 measles deaths were averted.3 Similarly, several cases of neonatal tetanus had been prevented by maternal immunisation and improved childbirth conditions. In 1987, 45% of children in developing nations were vaccinated against tuberculosis, similarly, there were 21%, 30%, 45% and 44% coverage rates for neonatal tetanus, measles, whooping cough and polio, respectively.5 Successful immunisation efforts against polio had led to the eradication of polio from America in 1990.3 By 1990, immunisation coverage had extended to 66% of children at 1 year age and EPI by then had prevented over 2 million deaths due to measles, neonatal tetanus and whooping cough in developing countries.5 These successes of EPI were indeed impressive, but much more was needed to be done as several challenges still remained to be addressed. During the 1990s, measles caused around 2 million deaths in children every year. Neonatal tetanus and pertussis continued to be significant threats to children. Polio cases still were at an estimate 250,000 annually.3 During this period, other relatively new vaccines such as pneumococcal, Haemophilus influenzae type b and hepatitis B vaccines were also developed and were under active consideration to be included in the vaccination schedule. 1990–2010 In many low- and middle-income countries (LMICs) around the millennium year, the vaccine-preventable diseases continued to be responsible for considerable morbidity and mortality, especially in children.6 During this period, major challenges faced by the EPI programmes were to ensure that there were management skills to assure that an adequate number of vaccines reach the susceptible population at the right time; ensuring the availability of funds to sustain the availability of vaccines, drugs, equipment and manpower. For the continued implementation of the EPI in LMICs, it was imperative to ensure continuous, adequate and reliable supplies of vaccines, drugs equipment and funds.7 Together with it, strategy building for programme and training of health workers are required to be scaled up. Further, health workers had to be supported in the field. As proposed in Alma Ata Conference of 1978, immunisation had been considered as an essential component of primary health care. As such primary healthcare should be strengthened and its reach should be expanded.8 With Health for All 2000, immunisation becomes an important component of primary health care. The priorities of immunisation programme before the start of millennium included: (1) continued use of existing vaccines as well as the introduction of new, more effective and more stable ones; (2) the development and enhancement of cold chain technologies to safely transport, store and distribute vaccines; (3) the improvement of injection technologies to ensure proper administration of vaccines and safe handling of injection equipment and (4) efficient program management that strives to achieve and sustain expanded coverage and service delivery through improved training, supervision, evaluation and community mobilisation. Expanding immunisation coverage against hepatitis B and yellow fever also were prioritised in areas where these diseases were endemic.9 In many countries, due to the long list of contraindications to immunisation, immunisation coverage was less than optimal before 2010.10 To overcome some of the challenges in vaccination, financing and capacity building new set of international institutes such as the Global Alliance for Vaccines and Immunization were set up.11 In the years which followed, it has proven vital in rolling out and scaling new vaccines in LMICs. 2010 Onwards Immunisation is a success story in itself which has saved millions of lives all over the world and continues to save lives every year. Measles vaccine alone averted 23 million deaths between 2010 and 2018.12 Since 2010, newer vaccines against major killer diseases such as pneumococcal, diarrhoea, cervical cancer, cholera, typhoid and meningitis were introduced in 116 countries. More than 85% of all infants were vaccinated annually, which had reached the highest level ever reported. The WHO has been expanding the reach and implementation of EPI in developing countries. In this regard, WHO started several initiatives such as the Small Countries Initiative. Under these initiatives, 11 European countries with population 2 million or less had resolved to co-operate to strengthen their health systems and immunisation programmes, share best practices and address common challenges. The Global Vaccine Action Plan (GVAP) was adopted by the World Health Assembly in 2012, aimed to help realise the vision of a world where everyone lives free from vaccine-preventable diseases. Its ambitious targets were expanded immunisation coverage, disease elimination, vaccine research and development, and financing. The Immunization Agenda 2030 (IA 2030), a new strategy was launched in 2020 to carry forward the vision of GVAP and accelerate towards universal immunisation. The core principles of IA 2030 are people-centered, country-owned, partnership-driven and data-guided.12-15 IA 2030 for the decade 2020–2030 is conceptualised based on lessons learnt, challenges posed by infectious diseases and opportunities available to meet these challenges. It aims at maintaining the hard-won gains of immunisation and achieving more by leaving no one behind in any situation and at all stages of life. It provides a long-term framework for the current decade and operationalise through regional and national strategies. IA 2030 sets up a mechanism for ensuring ownership and accountability along with monitoring and evaluation in guiding implementation throughout the country.12 Then, the immunisation programmes while successful, have faced multitude of challenges such as vaccine hesitancy.16 As the world witnessed during the COVID-19 pandemic period, the role vaccines can play in fighting old and new pathogens; however, their delivery and access are ongoing challenges.17 Moreover, in the COVID-19 pandemic period, for the first time, the coverage with childhood vaccines declined, a reminder that the tasks should be continued.18 The Road Ahead The year 2024 marks 50 years since the launch of EPI and is perhaps the appropriate time to look back at the successes and challenges faced by EPI and look forward into a future where every life could be protected from vaccine-preventable diseases. There are two key changes since 1974 when EPI was launched. First, there are far more vaccines to protect from a range of diseases. Second, now focus is on life course immunization & vaccination for all age group & not just children.19 To make immunisation more effective, affordable, equitable and sustainable, there is a need for continuous research and knowledge sharing. Further, novel methods need to be developed for ensuring equitable distribution, regular supplies, policy planning, framing and implementation, these also require free flow of ideas and information. In keeping up with our conviction to promote and propagate recent research and knowledge and to mark 50 years of EPI, 'Preventive Medicine: Research and Review' intends to publish a special issue on the Expanded Programme on Immunization with primary attention on newer aspects of immunisation which will be helpful for academicians and researchers all over the world. We are looking forward to publishing articles which are evidence-based and would help forming informed policy, and implementation strategies for the vaccination programme. The indicative topics are provided in the Box 1.Box 1: Proposed themes/topics for evidence synthesis for special issue (indicative list)These topics are of public health interest and look forward to a deeper understanding of various aspects regarding vaccines. Our intention is to get nuanced research articles, review articles, commentaries and perspectives that focus on LMICs, in all continents in this world. We invite public health experts, policymakers, academicians, physicians, paediatricians and others to contribute to the special issue. All submitted manuscripts will be subjected to standard double blinding peer review process. Accepted articles will be available as open access. There are no submission or processing charges for the authors. The special issue is scheduled to be published in November–December 2024 and manuscripts to be considered for the special issue must be submitted on or before 30 June 2024. Manuscripts submitted after the due date may still be considered for our regular issues. The standard guidelines for authors need to be followed for the submission, with the only exception that there is no word limit for submission for this special theme issue. We hope that this special theme issue will contribute to improved health outcomes by better understanding of vaccine-preventable diseases, their available vaccines, their effects and adverse effects, vaccine policies, programme implementation and impact. Together shall we strive today for a better tomorrow.
Kumar et al. (Fri,) studied this question.
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