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IVAC Blog

 
Date: Sep 2013

This is the second in a series of profiles to help IVAC partners and friends get to know our team. This one features Chizoba Wonodi, an epidemiologist who leads IVAC’s Nigeria work. We caught up with Chizoba just before she made a big move back to Nigeria with her family. After living in Baltimore for 10 years, Chizoba will now represent IVAC in country, and she will dig deeper into efforts to work with the Nigerian government and other stakeholders to improve routine immunization and increase accountability.

Tell me a bit about your background and when you joined IVAC.

Before coming to Baltimore, I worked as a physician in Nigeria, concentrating mostly on adolescent sexual and reproductive health and HIV/AIDs prevention. I came to Johns Hopkins for my masters in public health and, after that, I went on to the DrPH (Doctor of Public Health) program, completing both programs as a Gates Institute Scholar. In 2006, in my third year of the doctorate program, a colleague introduced me to the PneumoADIP project that would later morph into IVAC. I thought the whole concept of accelerating access to vaccines was novel and cool and I wanted to be part of it. So I sought and got work as student research assistant with PneumoADIP.

When I graduated from my doctoral program in 2009, I joined the Hopkins faculty knowing I wanted to focus my work on Nigeria. My desire has always been to take what I learned at Hopkins and apply it to my home country. At IVAC, I have been able to do just that. My work is to support the Nigerian government in developing effective policies and programs to deliver life-saving vaccines to children. We work alongside many organizations, including the WHO and UNICEF, in helping the government build stronger immunization systems. We do this through policy and operations research, translating evidence to policy, and brokering or advocating for relevant interventions. Instituting accountability within the health system is also a big part of my work in Nigeria.

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Chizoba Wonodi with her niece. (Photo credit: Tyrone Shoots)

What inspires you to work in global health? 

I think the potential to make a difference on a large scale drew me to global health.  I came to this realization after medical school, when it was time to choose a clinical specialty. I considered pediatrics because I love children, but I didn’t have the affinity for one-on-one interventions when thousands were dying of preventable causes. I wanted to change things at a broader level. With public health, you can see how the policies and programs you implement affect large populations. 

What does it mean for you to be doing work to help Nigeria?

It is a privilege because not everybody has the opportunity to come to Johns Hopkins, a world-class institution, and receive training from the best in the field and work beside them.  It is wonderful to be able to take what I learned here back to Nigeria and try to make a difference there. However, it isn’t just about taking knowledge back, but also learning from the dynamic changes that have occurred in Nigeria.

Can you explain the kind of dynamic changes Nigeria has gone through?

There is more human capacity than before. In the last decade, a crop of globally educated public health revolutionaries – if I may call them that – have returned home with cutting-edge knowledge, skills, and attitudes. They’ve melded the global perspective with their local knowledge and sensibilities and have become a force for change. They resist doing business as usual and push for decisions to be evidence-based. They are forging partnerships in unusual places, demanding accountability, and focusing on results not just inputs.

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Chizoba Wonodi at the National Vaccine Summit in Abuja, Nigeria, April 2012. (Photo courtesy of Tyrone Gibson)

In the vaccine world to be exact, there has been a growing awareness of and greater access to new vaccines. For instance, Haemophilus influenzae type B (Hib) vaccine was introduced last year, hopefully next year, pneumococcal conjugate vaccine (PCV) will follow. Although it took more than 15 years for these new vaccines to become available in the country, the momentum is shifting rapidly as more stakeholders acknowledge the importance of immunization. In April 2012, we saw a massive outpouring of support and promises at the National Vaccine Summit. Many hands are now on deck to help prop up the routine immunization system, and we are seeing positive results. Top among the donors is GAVI, who provides the single largest investment in routine immunization in Nigeria. As more partners come on board, the program space gets crowded and the pace quickens. It is all very exciting. However, one has to be nimble and responsive, to be relevant.

What has been your most rewarding or memorable experience at IVAC?

Seeing the impact of the policies we’ve helped influence result in access to new vaccines for children has been most rewarding. I remember when I came to the PneumoADIP and we were working on the introduction of PCV into developing countries. At that time PCV was considered too expensive for poor countries, but by getting countries to recognize the burden of pneumococcal disease, by convincing vaccine manufactures that there was a market beyond Europe and America, and by mobilizing the right financing, we (and others) helped accelerate PCV introduction into Africa and Asia.

Six years later, it is gratifying to see PCV introduction has outpaced earlier projections. This means many more children (in the millions) are being vaccinated and protected than we ever thought possible. There aren’t many opportunities where you get to contribute to change as big as that.  

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At the National Vaccine Summit in Nigeria (left to right): Dr. Ado Mohammad, Executive Director of the National Primary Health Care Development Agency; Dr. David Okello, former WHO Representative for Nigeria; and Dr. Chizoba Wonodi, Epidemiologist and Nigeria Projects Lead at IVAC. (Photo courtesy of Tyrone Gibson)

Wow, that sounds wonderful but also very demanding. What do you do in your free time to relax?

I like to cook. I watch the Food Network to learn new recipes. I love Asian food so I started learning to cook Chinese and now Korean food.

Speaking of cooking and eating, if you could have dinner with anyone – alive or dead – who would you pick and why?

I would choose Nelson Mandela. I don’t think there is anyone in the world as loved and as esteemed. I would like to feel the essence of the man and understand what makes him stand out so much. It would be a wonderful opportunity to learn from someone who has so much compassion, knowledge, and wisdom.

So through our conversation so far, it is obvious you are very proud to be Nigerian. What about Nigeria do you like best?

I love the people. We are proud and very happy people. In fact, there was a study that found Nigerians are the happiest people on earth. You wouldn’t think that given all our challenges and issues; but that is just who we are. We are very welcoming and very hospitable. And I love that when you meet a Nigerian, they proudly proclaim they are Nigerian.

What is your wish for Nigeria?

My immediate wish is that the 2015 elections will come and go flawlessly without any major upheavals. I also hope that the bloodshed in the north will stop so people can get back to living their lives. And I wish that Nigerian leaders would recognize and build our biggest resource – our human resources. Part of that includes making sure girls are educated. Once girls are educated, half the job is done in terms of alleviating poverty, adopting healthy behaviors, and nurturing the next generation.

Lastly, if you could visit anywhere in the world, where would that be and why?

Bhutan. I had a colleague that worked at the Hib Initiative who visited Bhutan. It is very difficult to go there, and you need to have a special reason to visit. My colleague went as a part of a vaccine delegation and she said the country is just pristine, the air is clean and clear, and you can hear birds chirping everywhere. I would love to see that country which has been unspoiled by modern life. 

By Lois Privor-Dumm and Bruce Lee

You are having 100 guests for an outdoor picnic and need to make the decision:  do you buy big bottles of soda (potentially messier but less expensive), smaller bottles (potentially more convenient but also more expensive), individual cans, or a compromise between the two? Your decision will depend on several factors including available refrigerator space, price, convenience, expected number of guests, and probability of leftover soda. You may also consider the servers (adult or child), the risks (e.g. mess, amount consumed) availability (will there be enough, is there a need to ration?), and waste produced (e.g., aluminum cans versus plastic bottles).

Primary Container Policy Brief

IVAC’s new report, Coverage, Cost and Safety Impacts of Primary Container Choice.

Sound familiar? It’s a very similar decision process for vaccines – which must consider the price to the country, if there is enough storage space, how difficult is it to transport all of the required product to where it needs to be, how much wastage will there be, if is there enough for everyone, and what is the risk that some containers will remain unopened?*

Looking at shelves in a grocery store, it is clear marketers understand the dynamics of these everyday decisions. Companies like Coca-Cola fully research how consumers make decisions and weigh trade-offs of price, size, and convenience. They vary offerings by region and by store, limiting choice in some places and providing every option under the sun in others.

Interestingly enough, where the stakes are very high – in vaccines – there doesn’t seem to be the same level of consideration. No one gets sick if a bottle of Coke is not available. We wish the same were true with a vaccine. Yet countries, donors, and manufacturers often do not fully weigh the consequences of container choice on cost, availability, likelihood of usage, and safety. 

IVAC’s new report, Coverage, Cost and Safety Impacts of Primary Container Choice, details these tradeoffs and calls on the public health community to take a more data-oriented approach to supporting decisions for each individual vaccine. The report uses various scenarios run on the Highly Extensible Resource for Modeling Supply Chains (HERMES) model of the Benin vaccine supply chain built by the HERMES Logistics Modeling Team, working with colleagues from the Logivac Project and Benin. The HERMES Benin model allowed us to change the size of a vaccine container and simulate the resulting effects (e.g., cost per dose delivered and vaccine availability). The effects depend on a number of factors, including other vaccines in the supply chain, current constraints, and wastage policies (e.g., is a vaccine vial opened or not depending on number of children in a session). 

We also considered what could happen at particular locations and clinics...not just at the country or global level. This is important since country-wide measures of routine vaccine coverage may be misleading. Often, country-wide routine vaccine coverage is high (>90%) even when coverage in remote areas (where vaccines are needed most urgently) remains low. Remote areas also may be very difficult to reach, have limited refrigerator space to store vaccines, and offer poor access to health care, all resulting in limited vaccine availability and high disease risk. At the same time, fewer children may show up to be vaccinated on a particular day, making healthcare workers loath to open a vial if they want to avoid wasting unused doses and country policies may compel them to do so. There is also an additional scenario to be considered for countries or even communities that are risk averse. Some product presentations inherently carry with them an increased risk for contamination (particularly multi-dose vials if not handled appropriately) or error (e.g, when a lyophilized vaccine is reconstituted with product other than diluent), or even contain a preservative that may be perceived to have safety issues (as is the case with thiomersal in some high- and middle-income countries). In this scenario, containers not requiring preservative or single-use presentations may be preferred, even when space is limited and/or cost may be higher.

At a global level we must start looking at the unique characteristics of each new antigen, providing guidance well in advance of product introductions, and looking across a range of scenarios. Although it is tempting for the manufacturer to limit the number of product presentations, building a case based on simulation experiments from a variety of countries, considering implications on coverage, cost, safety, and feasibility could help manufacturers better understand the investments needed and the “cost” of getting it wrong. Furthermore, the global community can better appreciate why certain costs may be higher for some populations and evaluate the need for more specific guidance on individual vaccines across a variety of scenarios. Container choice is not as straight forward as looking at price, wastage, and space. When humans are involved and there are imperfect choices, we should be approaching the decision with a framework that considers global, local, and manufacturing implications to make better-informed choices for every product introduced.

A number of efforts are underway that have improved forecasting and enabled a more systematic view of cold chain space. Now is the time to invest in ensuring we understand the full picture of cost per dose delivered, availability, and safety for each individual product and scenario to make better informed decisions.

 

*When there is a mismatch between number of doses in a vial or container and expected session size (e.g. the health worker sees two children per day and has a 10-dose vial of vaccine) and there is concern about wastage or availability of vaccine for future sessions, some health workers may not open the vial and vaccinate those children that particular day. The multi-dose vial policy, which enables the vaccine to remain opened for a designated period of time, can help mitigate wastage concerns, but it isn’t always followed, and not all vaccines are eligible.

 

Lois Privor-Dumm, MIBS, is Director of Policy, Advocacy & Communications and Bruce Lee, MD, MBA, is Director of Operations Research at IVAC.