Beyond expectations: 40 years of EPI (Expanded Programme on Immunization)
Margaret Chan
Director General, World Health Organization
The Lancet
Volume 383, Issue 9930, Pages 1697 – 1698, 17 May 2014
doi:10.1016/S0140-6736(14)60751-0

[Excerpt; Editor’s text bolding]
The Expanded Programme on Immunization (EPI) was established by the World Health Assembly in 1974 at a time of great optimism for public health. The imminent certification for the eradication of smallpox was taken as proof of the power of vaccines, delivered in well-managed programmes, to permanently improve the world.1

When EPI was established, only about 5% of the world’s children were protected from six diseases (polio, diphtheria, tuberculosis, pertussis, measles, and tetanus) targeted by four vaccines. Today, that figure is 83%, with some low-income countries reaching 99% immunisation coverage.2 The number of public health vaccines being used for universal protection has more than doubled since 1974. Almost all countries include vaccines against hepatitis B and Haemophilus influenzae type b in addition to the original six diseases, and quality-assured vaccines are used in 97% of all countries.3 Today, WHO estimates that immunisation programmes save the lives of 2•5 million people each year and protect many millions more from illness and disability.4 With the certification of WHO’s South-East Asia Region as polio-free, 80% of the world’s population now lives in a country where polio has been eradicated.5

What accounts for this success? Does EPI offer lessons of broader relevance as the world prepares for the post-2015 era? EPI had some advantages from the outset. The prevention of childhood deaths has great public and political appeal, and that helped create momentum within individual countries and the international community to support immunisation programmes. Vaccines are scheduled interventions that can be delivered even in the absence of well functioning health systems, and even in places where capacities are weak and skilled health workers are scarce. The costs of the initial six EPI antigens against polio, diphtheria, tuberculosis, pertussis, measles, and tetanus were low.

But EPI’s success must be attributed to more than these advantages. During the past four decades, EPI has encouraged new models of international cooperation, found new sources of funding, and stimulated innovation in technology and the operational performance of national immunisation programmes.3 EPI has also pioneered improvements in surveillance and monitoring as a contribution to accountability for results.3 Fundamental public health capacities have also been strengthened; as just one example, there are nearly 700 laboratories, in 164 countries, accredited by WHO to undertake laboratory-based surveillance for measles and other vaccine-preventable epidemic-prone diseases.6…

…I see many signs that this desire to aim ever higher, with ambitious yet feasible goals, such as exceeding the Millennium Development Goal for reducing childhood mortality, eliminating a number of the neglected tropical diseases, and reducing tuberculosis deaths by 75%, will characterise the post-2015 era for public health. The future of global health can benefit from the pioneering work done by EPI in many respects—for example, finding new ways to secure and increase funding, fostering cooperation between multiple partners to work together with shared yet flexible strategies, stimulating industry innovation, and promoting country ownership through the streamlining of programmatic demands. Above all, EPI carved out pathways and strategies to achieve universal access to immunisation services. This legacy provides guidance for reforms that move health systems towards universal coverage, another worthy ambition for the future…