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This week in Geneva, health ministers from governments around the world will meet at the 65th World Health Assembly (WHA) for their annual meeting to discuss health issues that affect everyone everywhere. For those of you unfamiliar with this assembly, it’s a bit like a parliament of health ministers. They meet, discuss pressing health issues, put resolutions to the floor and vote. Among the resolutions they will consider is one supporting the Global Vaccine Action Plan, a road map to ensure that by the end of this decade, every child, everywhere enjoys the full benefits of immunization.
The plan is the cornerstone of work to date of the Decade of Vaccines Collaboration, sponsored by the Bill & Melinda Gates Foundation and chaired by global health leaders Ciro de Quadros (Sabin Vaccine Institute), and Pedro Alonso (Universidad de Barcelona). This impressive document is the result of an 18-month consultation involving more than 1,100 stakeholders from 142 countries. The plan sets ambitious new goals for the decade, establishes strategic objectives and identifies the actions that will support their achievement. Perhaps most importantly, it puts developing countries at the center of the plan and stresses country and community ownership of immunization programs as a key pillar for success in the decade ahead.
As a member of the DoV Collaboration’s Steering Committee, I’m pleased to see the plan reaching the WHA this week. It represents a huge collective effort. But it is also important to remember that global health is full of plans for this and plans for that. The endorsement of the plan by the WHA should be viewed as the beginning, not the end of our work. Turning the document into actions that move the needle on research, vaccine access, and ultimately, child survival will require continued investment and commitment of everyone from lab scientist to front line health worker and from head of state to head of household.
As Save the Children notes in a paper published this month, we’ve succeeded in delivering a full package of most basic childhood vaccines to four out of five children born on the planet, but nearly 20 million children remain incompletely immunized. Children whose mothers have received no formal education are only half as likely to get vaccinated as those whose moms have a secondary education, for example, and rural children are just under half as likely to get immunized as those living in urban areas. In an era where cell phones, soft drinks and Facebook are ubiquitous in every corner of the world, we can and should work to overcome inequalities to ensure that the same can be said for life-saving vaccines.
The plan outlines clearly the ambitious but achievable goals of the Decade of Vaccines: achieving a world free of polio; meeting all global and regional disease elimination targets; meeting vaccination coverage targets in every region, country and community; developing and introducing new and improved vaccines and technologies, and exceeding the Millennium Development Goal 4 target for reducing child mortality.
We have our work cut out for us, to be sure – and achieving these goals will require that we all do our part, and that we go beyond even Ministers of Health to engage other stakeholders and communities. Specifically:
Countries must commit to immunization as a priority, and work to strengthen their immunization systems
Families must understand the value of vaccines, and demand immunization as both their right and responsibility
Manufacturers must continue to innovate and deliver quality supply at affordable prices
Donors and governments must ensure funding for immunization programs is predictable and consistent, and
We must all work together to ensure that the benefits of immunization are equitably extended to all people.
I’m hopeful the ministers present at the WHA will approve Global Vaccine Action Plan this week in Geneva. But I’m even more focused on what happens when the Ministers go home and how the effort engages stakeholders beyond national governments. In a world where corporations, foundations, and non-governmental organizations can be as powerful as some governments, a winning plan for the Decade of Vaccines will require including all the players who can help to achieve this common goal. With all the players involved, and a sustained team effort, it should be a winning game plan.
Dr. Orin Levine is the Executive Director of the International Vaccine Access Center.
Children in Phalombe, Malawi. Photo by Matt Feldman / IVAC.
Understanding the major causes of child mortality is essential to establish health priorities and improve the health of children globally. Over the past decade, WHO and UNICEF’s Child Health Epidemiology Reference Group (CHERG) has strived to meet this need by publishing national, regional, and global estimates of the causes of child mortality. This information has been crucial to the development of child health interventions and long-term child survival strategies.
Since CHERG’s first report, estimation methods and the quality and quantity of child mortality data reported by country vital registration systems have drastically improved. This week, a new CHERG report presents for the first time annual disease-specific time trends for causes of child mortality over the past decade.
The new data, published in The Lancet, show that child mortality fell by 2 million deaths, from 9.6 million to 7.6 million between 2000 and 2010. According to CHERG, declines in mortality over this period are likely due to improving socioeconomic factors and the successful implementation of child survival interventions in developing countries, particularly those targeting nutrition.
But what continues to claim the lives 7.6 million children around the world every year? Infectious diseases are the main culprits–responsible for 64% of all deaths in children under five. And notorious killers, pneumonia and diarrhea, remain important causes and together were responsible for more than 2 million deaths in 2010. Sadly, a striking 40% succumb within the first month of life most often due to complications related to preterm birth.
Despite the historical drop in mortality seen between 2000 and 2010, the current rate of mortality reduction is insufficient to achieve the fourth UN Millennium Development Goal (MDG4): reduce the child mortality rate by two-thirds, before 2015.
Rapid introduction and scale-up of existing child survival strategies focused on infectious and neonatal causes, particularly in high burden areas of Africa and southeast Asia, is critical for achievement of MDG4. There’s reason to hope, however, with the continued rollout of life saving vaccines for pneumococcal disease and rotavirus by GAVI Alliance and its partners at an unprecedented pace, and at a price low-income countries can afford. But vaccines alone won’t stop pneumonia and diarrhea–other proven interventions such as improved nutrition, appropriate antibiotic treatment, and breastfeeding are also essential elements in this fight.
This newest CHERG report provides a valuable picture of the current state of child mortality worldwide. The data will allow policy makers to prioritize introduction and scale-up of effective interventions to reduce child mortality. CHERG’s job, however, is not over: monitoring the evolving causes of child deaths will continue to be a crucial part of global efforts to erase the 7.6 million child deaths that still occur each year.
Various vaccine containers at a clinic in Malawi. Photo by Matt Feldman / IVAC
By Lois Privor-Dumm
Single dose vial, multi-dose vial, pre-filled syringe or other system? At first blush, the decisions countries make when selecting which size container to purchase for national immunization programs seem simple. Limited budgets often lead low-income countries to prefer vaccines in multi-dose vials; multi-dose vials can be purchased and transported more cheaply and require less storage space.
All doses in an open vial must be used within a certain time after opening—any doses left over after that time are expired and must be thrown away to avoid contamination or reduced efficacy. Historically, with common vaccines priced at just a few cents per dose, a health worker could open a 20-dose vial of vaccine even if they weren’t able to use all of the doses before expiration; that worker would be able to discard the remaining doses for just a few cents in wasted cost.
So if multi-dose vials generally cost the country less to procure, why pay more? This is where the decisions become more complicated, running into trade-offs between lowering cost and increasing access. For instance, in scenarios where clinics see just a few children at a time, multi-dose vials can lead to missed opportunities to vaccinate. Let’s say that only three children come to be vaccinated on a certain day, and the vaccine is in a ten-dose vial. The health worker must decide whether to open a new vial—wasting seven doses but vaccinating three children—or to turn those three children away for the day, saving the vial until there more children at a single session. When the vaccine is just a few cents per dose, the choice is easier, but as complex, next-generation vaccines priced at a few dollars per dose make their way to the developing world, margins for error shrink and concerns about wastage become very relevant.
In addition, if a worker facing the above dilemma tries to use doses from an expired open vial in order to avoid wastage, there may be serious health risks to the patient. Although safety concerns can be mitigated in various ways, adverse events have been observed in various settings and are documented in the literature. Countries must have good systems in place to detect when safety issues occur, and they must make difficult decisions about how best to act in order to minimize risks without increasing costs or reducing access.
As more new vaccines are developed and manufacturers face container decisions early in the process, taking an evidence-based approach to the diverse needs of stakeholders is essential. There are models to evaluate the supply side factors impacting vaccine presentation, such as the cost of a vaccine, possibility of wastage, and ease of transportation and storage. If we build on these models, adding safety, political considerations, access and other stakeholder concerns, we may have a framework for decision-making and the first steps towards a way forward.
It may be easier said than done, but IVAC is taking steps to develop such a framework. We’ve partnered with WHO & PATH Project Optimize, vaccine manufacturers, and John Snow, Inc. to bring together more than 30 of the world’s top experts in the areas of vaccine introduction and development, cold chain, safety, quantitative modeling and more. We’re getting everyone in one room in order to examine these issues, and we have high hopes for the development of a comprehensive, systematic approach to this complex issue.
Today, April 24th, is World Meningitis Day. Meningitis is a major cause of child mortality, much of which is vaccine preventable. To mark this important day, we have invited the Meningitis Research Foundation to blog about the disease and talk about their work to save lives from this frightening disease in Malawi. To find out more about World Meningitis Day, please visit the Confederation of Meningitis Organizations (COMO) here.
By Meningitis Research Foundation
Meningitis in Malawi
Children at Healthy Center, Phalombe, Malawi. Photo by Matt Feldman / IVAC
In Malawi, meningitis is far more common than in industrialized countries, and rates of death from meningitis are unacceptably high compared to other countries in sub-Saharan Africa. In children under 5 years old, who are the most vulnerable to meningitis, two thirds of those affected die from the illness, which contributes to the high childhood mortality in Malawi.
Although meningitis vaccines are having a tremendous impact in many countries in Africa, they do not yet provide the complete solution for meningitis in Malawi. Since Hib vaccine was introduced in 2002, Hib meningitis declined but has not been eradicated. Pneumococcal vaccine has also been recently introduced in Malawi, but does not protect against all strains causing pneumococcal meningitis, and many other common bacterial causes of meningitis in Malawi are not covered by currently available vaccines.
Barriers to Receiving Treatment
As vaccine programs are implemented and new vaccines are developed, it is just as important to treat the people who are affected by meningitis now. With this in mind,Meningitis Research Foundation(MRF) funded research in Blantyre, a city in the south of the country, investigating the barriers preventing timely treatment of meningitis. The study found a lack of access to knowledge about meningitis, its symptoms and the importance of early treatment amongst health providers and the general public.
Patients can also be delayed by transport costs and other barriers, meaning that they do not reach hospital until the disease is already very advanced. Unfortunately, when patients do reach health care centers, there may be further problems getting access to the care they need. Treatment is delayed in 25% of meningitis cases, because they are initially misdiagnosed as malaria.
Action Meningitis Project
Meningitis Research Foundation has initiated Action Meningitis, a project in Blantyre, to break down these barriers to treatment, improve healthcare delivery and treatment rates, and ultimately to save lives of Malawians affected by meningitis.
The Action Meningitis project will target health providers to improve early recognition of meningitis and other bacterial infections, preventing misdiagnosis and prompting action for seriously ill patients. Mobile Health (mHealth) will increase accessibility of information using mobile phones and an electronic treatment pathway to improve diagnosis and appropriate treatment of patients.
Action Meningitis will also provide community awareness messages and symptoms information to the general public, particularly for mothers and care givers of young children.A series of radio programs will be broadcast across the country aiming to reduce meningitis deaths by raising the understanding of meningitis and bacterial infections, and to encourage communities to take action on health issues.Community groups will help develop suitable and comprehensive public awareness information that will be made available in various local languages.
Action Meningitis will also provide communities with bicycle ambulances to help get people to health care centres for medical attention and improve early treatment rates.
Future Impact
MRF is partnering with the Malawi-Liverpool-Wellcome Trust, Medic Mobile, Queen Elizabeth Central Hospital and the Ministry of Health in Malawi to develop the project in consultation with Health Care Workers as they will have a key role in making Action Meningitis effective and sustainable over the long term, while the participation of community groups will continue to ensure its relevance and benefit to the wider population of Malawi. Through these efforts, we are aiming to lessen meningitis’ hold on the country each year as we mark World Meningitis Day.
Have you ever been to the movies and seen a trailer for a film that you previously had no interest in seeing and then suddenly thought to yourself “That is a film I CANNOT MISS”?
That was the idea behind GAVI’s most recent production. It’s a three-minute film by a talented young American film maker called Ryan Youngblood that I stumbled across in Kigali one day and I think he and producer Doune Porter more than fulfilled their brief.
On April 26, during WHO’s first-everWorld Immunization Week, Ghana will introduce not just one but two new vaccines into its immunisation programme.
The pneumococcal and rotavirus vaccines will protect infants against the leading causes of the two biggest killers of children in Ghana and throughout the developing world – pneumonia and diarrhea.
The GAVI Alliance and our partnersUNICEFandWHOare working with Ghana’s Ministry of Health to plana massive celebrationin Accra at which the first children will be vaccinated.
On the same day, halfway across the world in Atlanta, Georgia, USA, our friends at the UN Foundation will be launching theShot@Life campaignto encourage the American public to champion vaccines as one of the most cost-effective ways to save children’s lives around the world.
It’s such an exciting time to be working in global health and, as more and more power brokers embrace the value of investing in people’s health, we are literally seeing progress across the world on a daily basis.
As you can imagine, back in Ghana our colleagues are feeling more than a little pressure and this film brilliantly captures the careful, methodical planning process that is involved in introducing new vaccines into the national health programme.
It also portrays the skill, wit and energy that Ghanaian health professionals are investing in this extraordinary initiative.
Like the best movie trailers, our little film has all the right ingredients to get you interested in wanting to know what happens next: handsome men, beautiful women, tragedy, suspense, despair, hope and raw determination!
Dan Thomas is Head of Media and Communications at theGAVI Alliance, a public-private partnership which aims to save children’s lives and protect people’s health by increasing access to vaccines in the world’s poorest countries.
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