By Dr. Kate O’Brien, Executive Director, International Vaccine Access Center (IVAC)
Everyone may get 15 minutes of fame, however, for common illnesses such as pneumonia headlines are scarce. While Secretary Clinton’s pneumonia diagnosis is viewed by most through a political lens, the candidate’s announcement has also sparked a curiosity about an illness contracted by millions every year.
Pneumonia, an infection of the lungs, is exceedingly common around the world with an estimated 450 million cases annually. In the US, about a million people seek hospital care for pneumonia with a cost to the health system of more than $10 billion each year according to the American Thoracic Society.
While the cost of pneumonia in the US is staggering, in too many countries the price is even higher. In the US, we have ready access to trained physicians with the know-how and equipment to make a diagnosis and when necessary, antibiotics and oxygen to treat illness. While some may balk at the cost, these interventions have been proven effective, and the vast majority of people who contract pneumonia make a full recovery. Sadly, this is not true everywhere.
In parts of Africa and Asia resources are scarce, and HIV infections, crowding, and indoor air pollution are prevalent and put people at risk. Also, the prevention and treatment measures we take for granted, such as vaccines and hand washing, are too often not available. The price of pneumonia in these countries is higher infection rates, more illness and, sadly, more deaths, especially in children younger than five years of age.
For most of my career I have been engaged in the fight against pneumonia. I have worked with nonprofits, governments and businesses to help families everywhere have access to the tools they need to fight this illness. We have made considerable progress. Vaccines to prevent the most deadly causes of pneumonia are rapidly being deployed in countries in most need—thanks to Gavi, the Vaccine Alliance, and country governments. As more children have access to vaccines and medicine to prevent and treat pneumonia, we see less disease and fewer lives lost. Yet, much work remains. More than 900,000 young children still lose their lives to pneumonia each year, these children need access to the same tools as our children, to prevent, diagnose and treat this common illness.
There is also a need to invest in innovations that will help those who contract pneumonia in the US and around the world. For example, pneumonia can have bacterial, viral, or occasionally fungal causes. Currently, there is no reliable test that will identify the cause of the infection in every case. The conventional method involves imaging, bloodwork, or cultures that are inconclusive in more cases than not. Physicians typically treat with antibiotics in case the infection is bacterial, but often the pathogen remains unknown. A test to identify the pathogen would help health workers everywhere to treat pneumonia appropriately and reduce unwarranted antibiotic use, this will help to address issues of antimicrobial resistance which threaten to undermine our ability to treat infections.
More than anything else, there is a need to put pneumonia on our collective radar as a public health problem that requires attention. Last year, pneumonia took more young lives than Zika, Ebola, malaria, tuberculosis, and HIV combined. Globally pneumonia is the leading cause of death for children under five years of age. Yet, pneumonia flies under the radar; it is so common that it is nearly invisible.
Can this change? Absolutely. This week, pneumonia is in the headlines and people are talking about their experience (or their parent’s or their child’s) with the illness. While pneumonia’s 15 minutes of fame may be about to run out, the chance to make a difference remains.
Kate O’Brien, MD, MPH is the Executive Director of the International Vaccine Access Center and Professor at the Johns Hopkins Bloomberg School of Public Health. She is a pediatric infectious disease physician, epidemiologist and vaccinologist.
In celebration of World Immunization Week, we asked some of our staff to reflect on their careers and why immunization is a critical tool in public health.
Here’s what inspires them:
What was the moment you realized you wanted to work in the immunization/vaccines field?
“It clicked for me when I was taking care of kids who had Hib meningitis during the late 1980's right after the vaccine was starting to be used in the United States.” – Kate O’Brien, Executive Director
“While serving as a Peace Corps Volunteer in West Africa, I worked with the local Ministry of Health's National Immunization Days for Polio. I spent a week traveling out to remote villages vaccinating children and providing Vitamin A supplements to prevent Polio.” – Matt Coles, Senior Program & Contract Analyst
“After completing my pediatric training I worked in Addis Ababa, Ethiopia as a pediatrician for two years and saw many children die of vaccine-preventable diseases, most notably measles and meningitis.” – Bill Moss, Deputy Director
What do you find rewarding about working in global health? In immunization/vaccines?
"Knowing how much of an impact vaccines can have on every family. Many families will never know the devastation of these preventable illnesses and knowing I contributed to that, even in a small way is HUGE for me.” – Lois Privor-Dumm, Director of Policy, Advocacy & Communications
“Being a positive part of a global community.” – Diane Coraggio, Research Associate
“Working in global health has allowed me to understand the root causes of poverty and disease that plague the majority of the world, and do so inequitably, and has provided me with the confidence and skills I need to contribute to changing the current situation and addressing those root causes.” – Olivia Cohen, Research Associate
“Immunization programs target healthy people and aim to keep them healthy. What better way contribute to public health?” – Kyla Hayford, Research Associate
What are you most proud of in your work at IVAC or in immunization/vaccines?
“I am always proud when the pediatricians and public health experts we have worked with advocate for change and speak up for needed interventions in effective ways - I love seeing a little bit of training and empowerment turn into something much bigger and better than we would have ever thought of!” – Lois Privor-Dumm, Director of Policy, Advocacy & Communications.
“I'm most proud of the impact our work has----it has tangibly and meaningfully contributed to actually moving the needle on getting vaccines to the people and places where they are most needed.” – Kate O’Brien, Executive Director
“It's especially rewarding when governments and policymakers use our work to make decisions around vaccines. “– Brian Wahl, PhD Candidate
What is something about immunization/vaccines that you wish more people knew?
“Vaccines are by far one of the most cost-effective public health solutions!” – Diane Coraggio, Research Associate
“Immunizations are the best buy out there-----there isn't anything that does a better job of preserving health and enhancing life.” – Kate O’Brien, Executive Director
What do you find most challenging about your vaccine/immunization work?
“There is so much to do and so little time! The vaccine world is a complex space and this field needs the best, the brightest, and all of our efforts to make accelerated progress.” – Kate O’Brien, Executive Director
“One of the most challenging things about successful vaccine work is that it can undermine itself. The disease goes away and people no longer understand how important vaccines are and they played in reducing the disease burden.” – Bill Moss, Deputy Director
What do think is the biggest challenge to closing the immunization gap?
“I think the focus needs to be more on the hard to reach with an understanding that where the greatest burden is (often where health systems are weakest) is truly the priority. There have been some examples of successful programs, countries, communities and the global health community need to focus on all aspects of strengthening immunization programs - both on the demand and supply side.” – Lois Privor-Dumm, Director of Policy, Advocacy & Communications.
“Delivery, delivery, delivery and optimizing the ways in which we use the vaccines we have.” – Kate O’Brien, Executive Director
“Reaching populations in areas of continuous conflict zones, refugee camps, and increasingly in areas of recent natural disasters.” – Olivia Cohen, Research Associate
“Improving accountability and governance in many developing countries and integrating immunization with other primary healthcare services will help close the gap.” – Brian Wahl, PhD Candidate
This post is part of the #ProtectingKids story roundup. Read all the stories here.
There is a popular saying that you cannot manage what you cannot measure. This is so true for the global effort to close the immunization gap. We need to localize and measure the gap before we can close it. Having good immunization data to evaluate how well we are reaching all children is a critical ingredient for success.
I was poignantly reminded of this fact a few weeks ago when I visited Damangaza community, an urban slum in Nigeria’s Federal Capital Territory, where one of our Women Advocates for Vaccine Access (WAVA) member works. A temporary settlement, Damangaza is made of mud huts, open sewers, zero infrastructure, friendly adults and playful children. This generous community hosts more residents than it can comfortably accommodate, even welcoming internally displaced families fleeing from Boko Haram. A mere 20 minutes drive from the heart of Abuja, the contrast in wealth and access between the community and the nearby Abuja city center couldn’t be any starker.
When WAVA member, Vaccine Network, began working in Damangaza a few years ago, majority of the children had never been vaccinated. The year before, an outbreak of measles swept through the community killing many children in its wake. Although by no means hard to reach, a community like this is one of many settings where children easily fall through the cracks and are missed by immunization services.
Little wonder current data shows that one in five African children is under-vaccinated. If we are to reach that fifth child, we need accurate and timely data to tell us who that child is, where they live and why they are missed. This is a big challenge in Nigeria where the two main sources of immunization data (survey and administrative) do not speak to each other.
Survey data is obtained by interviewing a representative sample of households in the communities about their child’s immunization status. The main ones are the National Demographic Health Survey (NDHS) or the National Immunization Coverage Survey (NICS) conducted every 4 to 5 years. Survey data is richer in details and considered the gold standard. Administrative data on the other hand is based on clinic and health facility records of children who are vaccinated in fixed or outreach posts; it is collated monthly. It is therefore more available to support program management.
Unfortunately, there is usually wide disagreement between the administrative and survey coverage estimates, with the administrative always higher than the survey for comparable years. For example, national coverage with the third dose of the pentavalent vaccine in the 2013 NDHS survey was 38% but 58% by administrative data. Put another way, survey says we reached nearly 4 in 10 kids while administrative says we reached nearly 6 in 10 kids. Which data is accurate?
Diving deeper in the NDHS 2013 raises concerns about retention in care and equity of coverage. For example, while 51% of Nigerian children get their first dose of pentavalent, only 38% end up receiving all three recommended doses, reflecting an absolute drop out rate of 25%. Furthermore, only a quarter of one-year olds received all required vaccines, while as many as 1 in 5 received no vaccines at all.
Looking the beyond the national average reveals staggering disparities by geography, residence, mother’s education and wealth quintiles. According to the NDHS, a child in the north western state of Sokoto is 32 times less likely to be vaccinated than his peer in the south eastern state of Imo. A child living in a rural area is 2.5 times less likely to be vaccinated than her mate in the city. If a child is born of a mother with no education, that child is 7 times less likely to be vaccinated than another child whose mother has secondary school education or more. Children from the poorest fifth of the wealth ladder are 11 times less likely to be vaccinated than their peers from the richest fifth.
Sobering statistics indeed. As I cradled adorable twins Hassan and Husiana in my arms during my visit to Damangaza, I knew the odds were stacked against them in terms of access to vaccination. Their mother had no education, she was in the lowest rung of the wealth ladder and they live in an urban slum. But then again, it struck me that their disadvantage can be overcome if we are intentional about finding and vaccinating children like them wherever they may be. But we will need good and timely data to do that. If administrative data over estimates coverage, we will have a false sense of accomplishment and still miss many children. If survey data is accurate but comes only twice in a decade, it is too infrequent to help us manage the program. We must find an alternative.
Dr. Chizoba Wonodi is the Nigeria Country Program Lead at IVAC.
As the global community works on ways to improve immunization data, I see a third way. This is to empower communities to generate and use their own data to track births and children’s immunization status. Through IVAC’s work on accountability for routine immunization in Nigeria, I have seen that it is possible use community structures like religious and traditional leaders or Ward and Village Development Committees to count how many children are born in the community every month. If health workers have an accurate number of births in their catchment area, the true target population, it is easy for them to measure how well they are doing with vaccinating kids.
Community structures can also be used to track dropouts or left-outs, tracing them right down to the compound and household where the children live. Such real time information will not only help the health worker do their job better, it will also give community leaders a sense of ownership of the immunization program. I look forward to the day when a village chief can tell his community’s target population and vaccination coverage; that day will bring us many steps closer to bridging the immunization gap. Data is not just for experts and nerds; it is for all of us.
Dr. Chizoba Wonodi is the Nigeria Country Program Lead at IVAC.
This post is part of the #ProtectingKids story roundup. Read all the stories here.
Lakki Marwat, Khyber Pakhtunkhwa, Pakistan
From birth to 15 months, 6 visits to the Immunization Center your child will be protected from 9 vaccine preventable diseases. Repeat after me and memorize these numbers as you did your tables in school.
As some 20 heads nod in agreement, I realized many women and girls sitting in this veranda may never have gone to school. This was an awareness session with community women of Lakki Marwat. The district in Pakistan's northwestern province of Khyber Pakhtunkhwa has a dismally low immunization coverage.
Although it was an all women session, many women had not taken off their burqa (the one which are more popularly known as the shuttlecock burqa which covers them head to toe with just a net near the face to let them see and perhaps breathe a little) for fear that a male glance may fall on them.
Although, I had heard a lot about Lakki Marwat, this was my first visit ever to the place. Khyber Pakhtunkhwa is a conservative province, but Lakki Marwat is by far the most conservative of all the districts.
I was conducting an awareness session with the community women in Lakki. I wanted to speak to young mothers and even mothers in law and tell them the value of vaccination, how it can save their children from diseases and, best of all, it cost them nothing for that. I was also very curious to find out, despite all the benefits, what prevented them from getting their children vaccinated and what could be done to improve the coverage.
I was amazed at the level of excitement and interest. They were all ears, listening in rapt silence. Giving me utmost respect and importance, they raised their hands and patiently awaited their turn if they had a query.
Pakistan is a large country with high child mortality and low immunization coverage. More than 1,000 children under five die each day. Just over half of Pakistani children are fully vaccinated against all nine diseases included in the EPI, with tremendous variation between provinces (Source: 2012-2013 PDHS). It is an important country in the immunization world, and among the last two still fighting the polio virus.
There are severe provincial disparities and marked variations in immunization coverage in provinces and districts, and by gender. A survey conducted to analyze the causes and barriers of routine immunization in three districts of Khyber Pakhtunkhwa (which included Lakki Marwat) by Japan International Cooperation Agency (JICA) late last year indicated an unfortunate 78 percent illiteracy rate amongst women in Lakki district. Knowledge of mothers that children require immunization six times was only 12 percent.
In a comparison on gender differences of children (12-23 months) who had missed routine immunization, that of girls in that area turned out to be 64 percent as compared to boys.
There are several demand and supply side challenges for this low and fragmented progress. Public awareness of benefits is low and local authorities don’t view immunization as a priority. The gap in immunization knowledge among the community impedes them from actively seeking immunization services.
But despite systemic weaknesses, the province is taking impressive steps to not only improve but improve equitable immunization coverage. Lakki Marwat will be amongst the three priority districts in which the provincial government will be working on social mobilization in 2016.
One thing was evident – this was not a place frequented by visitors from other towns, let alone women. I recalled when, during our discussion, the Khyber Pakhtunkhwa EPI Program Manager had, in a sort of challenging cum daring tone, suggested Lakki for the advocacy session with community, if I was really serious in doing a meaningful session. However, while confirming the date and venue, the District EPI Coordinator of Lakki had clearly said I should return home by evening alluding to the place not being safe for women to stay the night.
Knowingly leaving this last piece of information from any conversation I had with my family on my impending visit to Lakki, I did, however, return the same night travelling a good 13 hours on the road. In retrospect, it was one journey I found to be far more satisfying than many others I have taken in my quest to spread the knowledge about the value of vaccinating children against childhood diseases.
Huma Khawar is an IVAC consultant who works on immunization advocacy with stakeholders on the ground in Pakistan.
By Dagna Constenla, Gatien de Broucker and Jorge Martin del Campo
This article was originally published in the Dengue Vaccine Initiative newsletter on March 7, 2016, available publicly here. It is cross-posted here with permission. IVAC is a member of the Dengue Vaccine Initiative (DVI).
A public health emergency of international concern
It’s summer in Brazil now and the sweltering heat of the Northeast Atlantic coast of the country drives many people outdoors where they come into contact with the Zika virus. In Recife, the capital of the state of Pernambuco where a third of the 4,000 reported cases of microcephaly in Brazil have been reported since early 2015, many people cannot afford to buy insect repellent in their local pharmacies. Most families in this part of the country live in impoverished areas with no running water and near open drums that serve as breeding grounds for the mosquito vector. Air conditioning and window screens that could help keep the mosquitoes out are prohibitively expensive.
Today, 24 of 26 states in Brazil are grappling with the rapid spread of the virus. This outbreak, driven by the global trends of population growth, urbanization, globalization expansion of mosquito vectors and the effects of El Niño, shows no signs of abating this year. Every day up to five new microcephaly cases are diagnosed, creating chaos and a break down in primary health care as hospitals and clinics become overburdened with mothers whose babies are waiting to be seen by pediatric neurologists and other specialists.
While the link between Zika virus infection and microcephaly in babies is still under investigation, the sudden exponential rise of cases, following closely the rise of Zika cases is unnerving. This situation has forced the World Health Organization to declare the epidemic of microcephaly cases in regions affected by Zika virus a matter of public health emergency of international concern. If the link between Zika and microcephaly is proven biologically, and evidence are cumulating in support of this relationship, the impact of the mounting epidemic will be far-reaching for Brazil and countries and territories with active Zika virus transmission.
People in Brazil are concerned about the uncertainty and risk of this outbreak and the lack of information regarding the virus. The concern is even greater among pregnant women who don’t understand the long-term implications of the Zika virus on their baby’s life: will their baby’s head fully grow? Will their baby be able to talk and walk? Will they be able to hear? Will they be able to attend school?
The prognosis for children born with microcephaly varies, according to the National Institute of Neurological Disorders, depending on the severity of the symptoms, ranging from impaired cognitive development to delayed motor functions and speech. Brazil’s Health Minister and health care officials in Colombia, El Salvador and the remaining 21 countries and territories of the Americas with Zika outbreaks have advised women of reproductive age to delay pregnancy.
While the Zika virus is new to Brazil and other countries of the region, Aedes Aegypti, the mosquito that spreads the disease, is well known for causing other emerging infectious diseases like dengue, Chikungunya and yellow fever.
Macroeconomic impact of the Zika virus
Beyond the silent suffering among those directly affected by the Zika virus, state officials have raised concerns about the negative impact that the Zika outbreak will have on the economy of Brazil and beyond. One concern is the potential negative impact of the Zika virus on the tourism industry last month (February), just when the Carnival season begins, and during the Olympic Games scheduled for August 2016 in Rio de Janeiro. Though currently there are no travel restrictions imposed by the World Health Organization (WHO), there have been anecdotal reports about international airlines already cancelling or rescheduling flights for passengers that are traveling to the region that are pregnant or may become pregnant. Moreover, evidence is emerging on the impact that Aedes Aegypti diseases have on tourism revenues. In their 2009 report, Mavalankar and colleagues quantified the impact of Chikungunya and dengue on tourism revenues of three Asian economies: the state of Gujarat in India, Malaysia and Thailand. They reported a substantial loss of tourism revenues: an estimated 4% decline, which represents at least US$ 8 million for Gujarat, US$ 65 million for Malaysia and US$ 363 million for Thailand.
Added to the potential significant losses associated with tourism, the possible decline on foreign direct investment due to the Zika outbreak is a major concern. During the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak, mainland China reported a decline of US$ 2.7 billion and Hong Kong foreign direct investment inflows fell 62% in one quarter. When the outbreak ended, this decline in foreign direct investment inflows was reversed.
Investments in outbreak control and surveillance infrastructure may also be impacted by the recent Zika outbreak. Recently, Brazilian authorities invested considerable resources to prevent the growth and spread of dengue. Funding for dengue outbreak prevention registered an increase of 32% over the last four years, from BRL $ 947.7 million in 2012 to $ 1.25 billion, in 2015. This funding was invested in supporting surveillance and preventive measures as well as in studying dengue. These investments are expected to increase with the rapid spread of the Zika virus. As the government of Brazil continues to make investments on preventive and control measures of Aedes Aegypti diseases, the government will continue to make debt repayments in the absence of significant financial inflows to finance outbreak control and surveillance infrastructure.
The loss of productivity due to the Zika outbreak is an even greater concern. Children with microcephaly may not have the ability to achieve their full cognitive potential because they are generally born with impaired cognitive and physical development. Moreover, children who are physically and cognitively disadvantaged are less likely to attend school, resulting in lower educational achievement.
At a macro level, the Zika outbreak could have other long-term repercussions. The government in Brazil and other countries in the region are already advising women of reproductive age to postpone pregnancies anywhere from six months to two years. If women in the region observe these warnings for a significant period of time, there may be a decrease in pregnancies that will ultimately result in a decrease in population growth. This could negatively impact the continued productivity associated with the sizable workforce in Brazil and the region as a whole.
What can we expect?
In terms of opportunities in containing the spread of the virus, recent advances in dengue research have resulted in development of new tools that show promise for use in prevention and control of other Aedes Aegypti diseases. These include vaccines*, antiviral drugs, therapeutic antibodies, biomarkers for severe disease, and mosquito-control methods that are biological, genetic and insecticidal in nature. Many of these new tools will not become available for use for another three to five years. The full potential of these tools, in terms of decreased transmission and prevention of major epidemics of dengue and other Aedes transmitted viruses, will be realized if used together instead of independently.
There are several challenges that Brazil and other Zika-affected countries in the Americas face to contain the spread of the virus. Currently, an overall strategy is lacking to effectively use these new tools and to educate the affected communities. Funding for research in this area and operational program implementation are fragmented and often uncoordinated. However, Brazil’s institutional capacity to manage outbreaks shows promise. The Oswaldo Cruz Foundation is one of many credible, government-funded institutions working to characterize Aedes transmitted viruses, like Zika, and its epidemiology. Moreover, a strong community of health networks across all states in Brazil is helping to promote positive behavioral changes that can temper the spread of Zika at the community and household levels so, next year, when those sweltering in the heat of the Northeastern Atlantic coast of Recife come into contact with Zika, they may be at a lower risk of contracting the virus.
* Denvaxia® has recently become available for the prevention of dengue. There are many other dengue vaccine candidates in the pipeline. No vaccines are currently available to target the Zika virus.