Policy: Progress and Promise

Over the past decade, national governments and national and international health organizations have made significant strides in reducing the prevalence of vaccine-preventable diseases, significantly decreasing mortality. Yet, prevalence and mortality disparities between nations still exist. In this article, I hope to set up a case study identifying one possible solution to this disparity by looking at a single vaccine-preventable disease.

The following graph, taken from “Our World in Data” (OWD) displays the relative levels of mortality in 2019 caused by vaccine-preventable disease at the global scale. (1) Tuberculosis resulted in a vast majority of preventable disease mortality, accounting for roughly 1.2 million deaths. Additionally, meningitis, whooping cough, measles, tetanus, Hepatitis B, Diphtheria, and Yellow Fever all contribute significantly to vaccine-preventable disease mortality.

In this article, I set up a case study of Tuberculosis (TB). The BCG (Bacillus Calmette-Guérin) vaccine is most often provided to protect against the disease and it is generally administered once, while the patient is less than 1 year old. (2) The vaccine is primarily provided only in regions where TB is prevalent, and is not commonly used in the US. Furthermore, the BCG dosage is generally 0.1mL, although some providers recommend smaller doses for infants. (3)

Above, I provide a graph detailing TB mortality in different countries. (4) The disease is least prevalent in North and South America and Australia. Furthermore, India and South Africa account for roughly one-third of TB deaths worldwide. (5) The reason I chose Tuberculosis for this case study is because vaccination rate is directly related to mortality rate. Nations in which TB vaccination is common (documented by the share of one-year-olds vaccinated against TB) will best be able to reverse the effects of TB prevalence, resulting in fewer deaths from the disease. Below, I provide that second graph, representing the share of 1-year olds vaccinated against TB in the same year (2019). (6)

In regions where TB is prevalent (Africa and Asia), nations with high vaccination rates have smaller death rates. Looking at Asia, Russia and other north Asian nations with higher vaccination rates (dark blue) also have less TB mortality (light orange) when compared to South Asian nations that are depicted as lighter blue and darker orange.

While we do not think of TB as a life or death issue in the US, the disease is still prevalent in many parts of the world; the WHO’s End TB Strategy aims to reduce TB mortality by 2030. (7) The strategy has three main components: early detection, increased access, and continued research. Through new testing strategies, the WHO plans to implement means to detect TB at an early stage, reducing mortality; the WHO also plans to continue funding research and development while expanding access to TB treatment. (8, 9)

In this article, I will describe a possible plan that may help the WHO reach its goals, while also describing some potential logistical issues it may pose. Because vaccination is one of the best means of prevention for TB, I pose that implementing standing orders in nations where TB prevalence is high and creating a vaccine transfer system (VTS) will reduce prevalence of TB in developing nations while ensuring medical staff have enough resources to deal with the issue.

So what are standing orders? Standing orders are protocols that enable trained healthcare employees (nurses, pharmacists, etc.) to assess a patient’s health status and administer a vaccine without consulting a primary care physician or medical provider. (10) Standing orders are established via national, state, local, or clinic policy and generally apply to a specific medical practice (usually a vaccine) provided in an outpatient clinic, hospital, pharmacy, or long-term care facility. Standing orders are often implemented for Influenza, Pneumococcal, Hepatitis B, and Varicella vaccines but researchers are currently attempting to link standing orders to improved health outcomes for other preventable diseases. (11)

Applying standing orders to TB treatment may result in a few problems:

• Developing countries may lack the vaccines necessary to treat large volumes of patients. (12)

• Some nations may lack access to cold storage units and other infrastructure necessary to maintain large volumes of vaccines.

• Some nations may lack the personnel to administer vaccines, check up on patients, track immunization status, and maintain patient documentation. (13)

• Despite access to vaccines, individuals may lack faith in the medical systems of their nations and thus may be hesitant to make use of standing order policies.

To avoid these potential pitfalls, specifically related to lack of resource and infrastructure access, I argue that a vaccine transfer system would bring the needed TB vaccines to those who need them most. In this hypothetical transfer system, countries with large budgets and with significant research and development investment may provide vaccines at low cost to other nations where vaccines are scarce. For example, North America and Europe (where most of the population is vaccinated and where vaccines are in surplus) would provide vaccines at subsidized cost to Africa and South Asia (where a significant portion of the population is unvaccinated and where vaccines are in shortage).

This transfer system is similar to what transpired during the COVID pandemic. Countries with an excess of COVID vaccines and with low COVID prevalence (the US and some nations in the Middle East and Europe) provided vaccines to other nations. This system reallocated resources efficiently, improving access to vaccines and creating more equitable outcomes.

Upon identifying a public health issue, it is important to take a step back and analyze what factors might contribute to that issue before attempting to derive a solution. While standing orders might enable individuals in TB-prevalent nations to receive vaccines, providing more patients with vaccines may decrease hospital inventories resulting in severe shortages. Many public health and health policy interventions are multifaceted with different components addressing specific problems. While standing orders may improve access to TB vaccines, a vaccine transfer system will reduce shortages, an issue possibly exacerbated by standing orders.

Standing orders are not without merit; the policy enables trained hospital employees to provide care to patients without organizing a patient checkup or physician-conducted examination. Not only does this save time for the patient but it also might free up physicians to solve the most pressing issues. With the rise of long COVID and the continued production of new booster vaccines to address the possible re-emergence of the disease, perhaps the US and other national governments ought to establish standing orders for select COVID vaccines. Perhaps standing orders would be effective in screening for long-term or chronic issues such as breast cancer, CVD, and Alzheimers. If patients had easier access to breast cancer screenings via a standing order, perhaps they may seek treatment faster and at an earlier stage of the disease when treatment would be most effective.

As I end this article, I hope to bring up a final question that I left unanswered in my argument thus far. Having easy access to TB vaccines may not improve patient uptake if misinformation and health polarization result in individuals avoiding care. While standing orders may reduce mortality from vaccine-preventable disease globally, implementing policy is only one part of the solution; by building networks of trust between the government, healthcare providers, and individuals, we can create a world where institutional policy and programs contribute to the health of all.