This article was originally published on Global Health Now and is cross-posted here with permission.
By: Dr. Mathuram Santosham
A healthy child in Uttar Pradesh, India, 2010 © Gates Foundation
World Immunization Week provides a moment to reflect on the tremendous progress in reducing one of the world’s leading killers of children—diarrhea.
While oral rehydration solution has significantly reduced diarrheal disease mortality since its adoption in 1978, diarrhea continues to be a major cause of childhood illness and death globally. Rotavirus, the most common cause of severe diarrhea, is responsible for approximately 40% of all diarrhea hospitalizations and hundreds of thousands of deaths in children under 5.
Rotavirus vaccines offer the best protection for children and are an essential part of comprehensive diarrhea control. While the WHO recommends that all countries introduce rotavirus vaccines, only 77 have done so, 34 of which are Gavi-eligible countries where many of the deaths occur. Unfortunately, some of the most vulnerable children and communities do not have access to the vaccine.
In particular, Asia has lagged in introducing rotavirus vaccines, even though it accounts for more than 40% of global rotavirus deaths. To date, no country in the region has introduced the vaccine into its national immunization program.
While dramatic reductions in deaths from childhood diarrheal disease have been achieved in Bangladesh, there are still more than 2.4 million rotavirus cases each year. It causes 2 out of every 3 diarrhea-related hospitalizations among children under 5. There are also serious economic consequences. One episode of rotavirus costs the average Bangladeshi family about USD $80 in direct hospital costs, a significant portion of average monthly income.
In neighboring India, where rotavirus is equally ubiquitous, the disease poses a significant financial burden to families and the country’s economy. Studies have shown that a hospitalization for rotavirus could potentially push a family into poverty or keep them there. Depending on the level of care, the total cost of a rotavirus hospitalization could range anywhere from nearly $32 to more than $135, equal to up to 2 months of income for an average Indian family. Rotavirus also burdens the healthcare system with the high cost of hospitalizations and outpatient visits. One study estimated that hospitalizations and outpatient visits cost India approximately $78 million and $86 million each year, respectively—each more than the estimated $72 million it would cost to fund a rotavirus immunization program.
For fast-growing countries like India and Bangladesh, tackling rotavirus—which cheats children and the nation of productivity, well-being and development—should be a priority. However, the available and effective rotavirus vaccines are not yet available in the national immunization programs of either country.
Many of my scientific colleagues in Bangladesh are making a good case to their leaders for national introduction of rotavirus vaccines. And, I’m inspired by the strides being made in India. Last July, Prime Minister Narendra Modi announced that rotavirus will be included in the Universal Immunization Programme; and just last month, the first India-made rotavirus vaccine, ROTAVAC, was launched. Now is the time to get to the finish line—the cost of delaying access to rotavirus vaccines continues to mount. Together we can close this immunization gap and virtually eliminate rotavirus.
Dr. Mathuram Santosham is the Director of the Center for American Indian Health, Chair of the ROTA Council, and Senior Advisor at the International Vaccine Access Center at Johns Hopkins Bloomberg School of Public Health. Dr. Santosham and his colleagues won an Honorable Mention in GHN's Untold Global Health Stories Contest for their submission of rotavirus in Bangladesh and India. GHN will feature one Honorable Mention story per month from now until the next contest in early 2016.
This article was originally published in Open Magazine and is cross-posted here with permission.
This post is part of the #ProtectingKids blog series. Read the whole series here.
Niya Zameen with her two boys outside their home in Ramsar
Niya Zameen, 33, lives with her two sons in Ramsar, in Barmer district of Rajasthan. Her village has a population of just 1,078 and is close to the India-Pakistan border. Niya has always tried to ensure that her children receive the necessary healthcare services, including vaccines, to give them a healthy start in life. Getting her children vaccinated hasn’t always been easy because of shortages of government recommended vaccines. But Niya has never given up. With the help of the local health worker, Rampatti, she made sure that her children received the necessary vaccines against measles, polio, and three doses of diphtheria-tetanus-pertussis.
Of the 1.3 million Indian children under-5 that died in 2013, pneumonia claimed more than 175,000 lives and diarrhoea caused more than 130,000 deaths. Even in cases of survival, the severe burden of illness from diarrhoea and pneumonia adversely impacts children’s growth and development. But many of these severe illnesses can be easily prevented through immunisation. The pentavalent vaccine, that prevents a deadly form of pneumonia and meningitis, is now available through government immunisation programmes in some states and the vaccine to tackle diarrhoea caused by rotavirus, will soon be rolled out.
Niya Zameen acknowledges the crucial role that Rampatti, the local health worker, plays in her life. She has provided guidance on important health decisions, including the role of vaccines in giving all children protection against preventable diseases.
Vaccine delivery is a challenge in this region, due to extremely hot weather and the difficult desert terrain. If the vaccines don’t arrive on the designated day of immunisation, Rampatti travels to the vaccine cold chain point to collect them for her village. On her return, she vaccinates children.
Every child has the right to a healthy start, and it is the responsibility of not just the government, but also of the community to ensure that all our children are timely and fully immunised.
Photos by Shikha Nayyar
Mathu Santosham speaking at the Eleventh International Rotavirus Symposium in India.
This post originally appeared on the Impatient Optimists blog and is cross-posted here with permission.
Heading to New Delhi, India recently for the Eleventh International Rotavirus Symposium, I knew that this meeting would be different. Over the past couple of years, notable advancements against rotavirus disease have occurred, including the development of a new indigenously developed vaccine in India, an enormous mass of studies with positive safety and effectiveness results, and many introductions of vaccines into national immunization programs, giving promise that we can beat this leading killer of children.
In the very first moments of my arrival, I learned that my expectations were right.
Never before have more people gathered at this symposium. An astounding 650 experts from 56 countries —more than 16 times as many people who attended our first meeting thirty years ago — came to the conference, themed, “Building on evidence: the case for rotavirus immunization.”
The sheer number and diversity of people are true testaments to the increasing awareness of rotavirus and the essential role of vaccines in reducing the suffering this disease causes.
Pediatricians, epidemiologists, researchers, policy makers, immunization program implementers, government officials and pharmaceutical representatives presented on and heard about a number of important topics. Panels ranged from the Latin American and African experience with vaccines and post-licensure impact and safety of vaccination, to immunity and new insights in strain diversity.
In addition, we discussed the critical policy challenges remaining and advocacy efforts needed to help overcome them. Advocacy among policy-makers, championed by my dear colleague and friend, the late Dr. Ciro de Quadros, along with groundbreaking vaccine development efforts and public-private partnerships are leading to greater prioritization of rotavirus; however, more must be done.
But what also stood out was the excitement of convening this biannual event in India. The new government has made laudable commitments to tackling the burden of rotavirus, and other leading childhood diseases, that will save lives and give all Indian children a chance at being healthy and productive.
Just two months ago, Indian Prime Minister Narendra Modi announced that the Government of India would provide a rotavirus vaccine to all Indian children through the Universal Immunization Program. At the same time, the government has redoubled efforts to improve access to oral rehydration solution (ORS) and other key diarrhea control interventions through its Intensified Diarrhea Control Fortnight. All of these efforts are positive signs for the children of India.
At the symposium, Dr. Harsh Vardhan, India’s Union Minister of State for Health and Family Welfare, spoke about the importance of delivering vaccines to all those in need. Too many children have lost their lives, and too many families are bearing tremendous economic consequences as a result of hospitalizations due to rotavirus. In India, rotavirus is estimated to cause more than 78,000 deaths, 800,000 hospitalizations and three million outpatient visits each year.
However, even with this momentum, we must not become complacent in addressing rotavirus disease, the leading cause of severe and fatal diarrhea in children under five years of age worldwide, killing between a quarter and a half million children each year. While children everywhere are at risk of infection, the majority of deaths occur in South Asia and Sub-Saharan Africa, where children do not have good access to care.
Yet, despite the World Health Organization’s (WHO) recommendation for all countries to introduce rotavirus vaccines in their national immunization programs, only 35 percent of countries worldwide (69) have done so. The most disappointing statistic for me is that only one country in Asia — The Philippines — has introduced the vaccine nationally.
Additionally, while vaccination is the best way to protect children from rotavirus, a comprehensive approach will best protect child health and boost immunity. Vaccination should be part of a broad strategy that includes improved water, sanitation and hygiene; good nutrition; breastfeeding; ORS; and zinc supplementation.
I am hopeful that when we meet again for the next symposium, two years from now, we’ll have even more scientific and policy progress to celebrate and build on. Thanks to all of the dedicated rotavirus experts who participated and whose work is making a lasting difference in the health and well-being of children everywhere.
Thanks also to the conveners and funders: the Bill & Melinda Gates Foundation, U.S. Centers for Disease Control and Prevention, Christian Medical College Vellore, Indian Council of Medical Research, National Institutes of Health Fogarty International Center, PATH, ROTA Council, Sabin Vaccine Institute, Bharat Biotech, GlaxoSmithKline, Merck Pharmaceuticals, Serum Institute of India, Ltd. and WHO.
Learn more about how rotavirus vaccines can improve health and save lives at www.ROTACouncil.org.
By Dr. Kate O’Brien
Today is a landmark day, one that many global health experts thought might not happen. Today marks three years since the last case of wild polio in India, the requirement to officially certify the country, and with it the WHO South-East Asia Region, polio-free. While the official declaration is not due until March when a WHO Regional Certification Committee reviews all the data, today is a day to celebrate and to be remembered in India and around the world for years to come.
Photo Credit: Rotary International
It is a day to congratulate India, but also the global community. It is a day that gives us all strengthened hope and confidence in achieving the goal of global polio eradication. In 1998, India had a high of nearly 2,000 cases of paralytic polio from the wild poliovirus, and as recently as 2009, it still was home to most of the world’s polio cases. By 2011, it had wiped out wild polio cases, and now it has maintained that status for three years. India’s large, dense, and often migratory population combined with poor sanitation conditions in parts of the country created some of the most difficult conditions throughout the world to control disease. However, with a depth of commitment from all levels of government and civil society and dedication of significant resources, India achieved this mammoth goal. It could not have been done without the work of millions of individuals, including the 2.3 million vaccinators, the thousands of clinicians and epidemiologists in more than 33,000 surveillance sites, the religious leaders and advocates committed to on-the-ground outreach, and the leaders across government and industry who together contributed nearly US$2 billion in funding.
Thanks to all of these individuals, India is now polio-free, and its triumph over polio is a massive public health achievement---one that will leave a lasting impact on children's health in India and around the world. It is also a testament to the power of immunizations, which have been saving lives in India and around the world for centuries.
India has achieved a laudable reduction in global child deaths in recent years, and vaccines have been one of the most effective interventions in this effort. Not only have vaccines prevented deaths, but they’ve also helped children stay healthy and averted crippling social and economic costs to families and society. Beyond polio, India’s other great achievements related to vaccines are highlighted in this infographic.
Vaccines clearly work and they clearly work in India. As coverage levels increase and new vaccines are introduced into its Universal Immunization Programme, disease reduction will amplify, and children will lead healthier, longer lives. These inspiring efforts should be applauded along with India’s polio achievement.
India’s achievements should also inspire the global community to rededicate our efforts to ensure every child around the world is protected from preventable diseases. We have a unique window of opportunity to change history by eliminating polio from the three remaining countries where transmission has not yet been stopped – Pakistan, Afghanistan, and Nigeria – and maintaining disease control in other countries where elimination is fragile and polio threatens to return. With much learned from India’s success, communities, countries and the global community have a strong, actionable plan to achieve a polio-free world by 2018.
Ending polio everywhere, forever, is a critical step toward improving the lives of the world’s most vulnerable children. As India has clearly shown, polio eradication can lead the way for other child health initiatives, by strengthening surveillance systems, building networks of trained community health workers, and engaging leaders from across diverse disciplines. The job is not yet done; India and other countries around the world will need to sustain and continue to build on the progress to date while planning for the next step of introducing at least one dose of inactivated polio vaccine.
The remaining polio-endemic countries should have a deep sense of hope, bolstered by the accomplishments and lessons learned in India, that this goal is at their fingertips. The scientific, public health, communication, and organizational tools are in place. With the right political will, polio will be wiped out; there will remain substantial and at times unanticipated challenges to match the accomplishment of India in the remaining countries, but these are surmountable. There is a lot to be optimistic about. India has demonstrated to the world what is possible when the community in all its dimensions – local and global, political and religious, scientific and lay – has a common commitment. We call on all partners to continue without wavering the march toward worldwide polio eradication and in so doing achieve the purest measure of health equity.
Kate O’Brien, MD, MPH, is Executive Director of IVAC. A pediatric infectious disease physician, epidemiologist, and vaccinologist, she previously served as Deputy Director of IVAC. She also serves as Associate Director of the Center for American Indian Health.
This is the first in a series of profiles to help IVAC partners and friends get to know our team. We thought we’d start with Lois Privor-Dumm, a long-time IVAC team member and Director of our Alliances and Information team. We caught up with Lois in between her busy travel schedule to chat about her background, her work at IVAC and what she likes to do in her spare time.
Tell us a bit about your background, what inspired you to work in global health, and how you ended up at IVAC.
I didn’t set out to work in global health, but I’ve always wanted to work internationally. I spent most of my career in the private sector and was fortunate enough to have the opportunity to launch Prevnar®, the first pneumococcal conjugate vaccine (PCV), in the U.S. and then help other countries around the world introduce the vaccine. I had worked with other vaccines and pharmaceuticals, but this experience, coming in direct contact with families impacted by pneumococcal disease, particularly meningitis, made a major impression. I saw the value that the vaccine had for countries that had introduced, but also recognized the severe disparities that existed in vaccine access around the world. I decided I could play a role in helping reduce those disparities. Although I was able to influence some change while working in pharma, I thought I could make a bigger impact by bringing my understanding of the industry and my marketing and operations experience to public health. I was fortunate to be working with experts on PCV, including Orin Levine, Mathu Santosham and Kate O’Brien, who recognized how my perspective – despite my non-traditional background for a public health career – could be beneficial. We shared the vision that new vaccine introductions did not need to see delays of 20 years or more between licensure and introduction in low-income countries, and helping devise and implement a plan to achieve this goal was very intriguing to me.
So, I first joined Hopkins in 2005 as Director of Communications and Strategy on the Hib Initiative and soon after took on the role of Director of Access and Implementation, and later Communications, for the PneumoADIP. Our approach of addressing the needs of all stakeholders – countries, donors and suppliers – proved to be an effective way to achieve our vision, and we’ve been fortunate that we’ve been able to continue our mission through what is now IVAC. I consider myself very lucky to work with such a diverse, creative and talented team. I think it is the team and the way we work that has enabled us to work on some really tough challenges that have a big impact and achieve success.
I’m also a strong believer that there are always solutions and, at Hopkins, I value the opportunity to help facilitate those solutions, bringing both a manufacturer perspective and that of someone working with global health colleagues and country leaders. There’s been significant progress in vaccine access in the past decade or so, and I hope our work will continue to accelerate greater access and equity for vaccines and other interventions that make such a difference in peoples’ lives and contribute to healthier and more productive societies.
What projects do you work on at IVAC?
Lois Privor-Dumm and a group of children at the 1st National Vaccine Summit in Abuja, Nigeria in April 2012.
I lead the Alliances and Information team at IVAC, which includes projects covering advocacy and communications – both globally and in-country – as well as policy research and supply and access issues. I spend a great deal of time on our country-focused work, namely India, where we have been working to synthesize the evidence base and advocate for interventions for pneumonia and diarrhea at both the national and state level, and Nigeria, where we have helped analyze barriers and solutions to improve routine immunization and continue to provide technical support and encourage government accountability. I’m also excited that we’ve recently added country work with Pakistan.
Our work is varied, and there is never a dull moment. Our efforts have helped others become advocates and add their voice to important issues in child health. For instance, we’ve run advocacy workshops and collaborated with a network of trained experts to address child pneumonia and diarrhea in their countries. We support the efforts of experts including the ROTA Council, a dedicated council of scientific experts working to accelerate the introduction of rotavirus vaccines, and the Global Coalition Against Child Pneumonia. With the help of key partners, we established World Pneumonia Day to call for action on protection, prevention and treatment of the leading global killer of children. Our team also coordinates closely with IVAC’s Epidemiology and Economics & Finance teams to help communicate the results of their work and highlight the work of other researchers that relates to vaccines and child health.
Last but not least, I spend much of my time on our supply and access work, which is also very important. One of our more recent projects centers around primary container decision making and building awareness of how these seemingly straightforward decisions have significant impact on not only cold-chain space and procurement cost, but also wastage and other costs, vaccine coverage, and safety. We’ve developed a framework and have been working with various experts to help advocate for a more robust approach to considering all the implications of these decisions.
I’d be remiss not to mention, that none of this, of course, could be done without the great team of hard working and very capable individuals and students on the A&I team.
What have been some of your most rewarding or memorable experiences at IVAC?
One of my most memorable experiences was my first week at Johns Hopkins. I was working with the Hib Initiative and went to the Gambia and Bangladesh to film the BBC World Kill or Cure: Hib documentary, which highlighted the impact of the disease and efforts needed to bring a vaccine to developing countries. I remember meeting people at the labs and families that had been affected by meningitis and seeing how dedicated they were to finding the solution. I have great memories from that trip, for example touring the lab at MRC and then having tea with a family in the Gambia with little kids around very curious about all of our cameras. Bangladesh was no different, although it was tough seeing a child and her mother who did not know whether her daughter would survive the night or succumb to a severe case of pneumonia.
Another big moment was the first World Pneumonia Day in 2009 and seeing that kick off not only in the U.S. but probably more importantly around the world. That sense of pride continues when I see how many other people have taken up the cause. As we move into World Pneumonia Day’s fifth year, I am increasingly impressed by the level and volume of activities that take place – creating a global community of sorts. The fact that people are talking about antibiotic access, bringing new vaccines into countries, improving breastfeeding rates – it is very gratifying.
What is the most interesting place you’ve traveled to? Anyone who has seen your passport will know this will be a tough question to answer.
Yes, it is. Everywhere I’ve gone has been interesting. Large countries hold a lot of interest for me simply because of the level of contrast you see within the same country. I’m always struck by the disparities within the countries, but at the same time, the level of hope and generosity of those that don’t have much. I am fascinated by the diverse modes of transportation like the trucks that are brightly painted with “honk please” signs in India and Bangladesh, navigating the same roads as people walking with bundles of firewood on their heads or families piled three or four onto a small motorbike seat. In Nigeria I’ve been captivated by the people and the diversity of just about every aspect from dress to food, language and density of the population. And in some countries you’ve got such a long history that can’t help but impact you – Angkor Watt in Cambodia, Petra in Jordan, and slave quarters in Africa – it reminds me of how far the countries have come, yet how much more is still to be achieved.
Since you spend a lot of time in India and Nigeria, what similarities and differences do you see between the two?
Lois Privor-Dumm and fellow participants at a national course on pneumonia and diarrhea prevention in Delhi in December 2012.
That’s a great question. I’d love to hear the perspective from those who live in one of the two countries. From my perspective though, they are similar in that they both have some wonderful, high caliber people. Both have large bureaucracies and complex environments, and I’m always impressed by
individuals who’ve been great champions of children who’ve successfully been able to navigate the environment and overcome some real barriers to getting things done. The real heroes are the ones who’ve been able to not just talk about change, but have been able to see things through, and there have been examples in both places. Another similarity is that health is very much a state subject, and implementation and sustainable change is highly dependent on the individual states. As different as priorities and ways of life are between these countries, the same can be said of individual states, and it is important to understand the priorities and players in each.
Both countries obviously have had to tackle an ongoing challenge of polio, and the related challenges and opportunities of an enormous vaccine effort. India has now gotten ahead of the curve with no cases of wild-type polio for the past two years. Nigeria still faces many challenges with polio, but has moved ahead to strengthen routine immunization and add new vaccines.
One major difference may be in the way vaccines are portrayed in the press in each country. Although the dialogue is changing and more and more positive stories emerge surrounding vaccines, media in both countries still often like to report on sensationalist stories that do not hold scientific muster, and controversy reigns. Politicians and bureaucrats often do not recognize how political capital can be built by improving routine immunization. In Nigeria, although there are anti-vaccine sentiments, particularly surrounding polio in certain areas, health is an important issue, and leaders will take advantage of reporting on the steps they’ve taken to combat disease.
On a related note, what progress have you seen in vaccine access in India and Nigeria recently, and what do you expect to see in the next few years?
I think there is much more recognition in both countries that the systems must be strengthened, infrastructure for delivering polio immunization can be leveraged, and that a focus on bringing up routine immunization coverage will benefit new vaccines and vice versa. There has been a greater level of engagement at the state level, and I expect that this will become increasingly important moving forward. As states are implementers and must ultimately ensure that there is both adequate demand and supply, their engagement in the planning and decision-making process is key. Another area that should see improvement over the next few years is surveillance, not only to be able to measure the impact of the vaccines but also to be able to monitor any adverse events that may happen and to quickly determine if they are related to the vaccine. This has especially been a challenge in India, where activists and media have questioned whether adverse events are due to vaccine and have treated government assurances with suspicion. Good surveillance with baseline measures of child health statistics prior to introduction will make it easier to assess claims and address concerns that may be unfounded, as well as provide a basis for measuring the trends and impact that are so important to communicate to sustain public and policy maker support for vaccines.
On a personal note, when not traveling internationally, you split your time between Baltimore and West Chester. What do you like about each?
Yes, both places are great. West Chester is where I’ve lived for a long time, and where I spend a part of the week with my husband and dog. It is a historic city with brick sidewalks, and a small town where I’ve gotten to know a lot of people over the years. I consider it home, although I am originally from upstate NY. Baltimore is a great city. I love where I live in Fells Point, right by the water. I’ve got great colleagues and friends in the city, and the ability to walk to work is a huge bonus!
Do you have any interesting hobbies?
I like doing things outside, including spending time gardening, hiking and exploring different places old and new. But, there is no place I’d rather be than under the water diving (although on safari is a close second). I’ve been diving since 1992 and try to go every year. One of my favorite places is the South Pacific where you have just an amazing range of color and variety of marine life – sharks and eels and all sorts of different things. I think I like it because I’m an explorer at heart, and you never know what you’re going to find down there, and it’s a way to really relax.
What is the most recent book you’ve read?
I just read Cutting for Stone about a doctor from Ethiopia and am now reading Behind the Beautiful Forevers – Life, Death and Hope in a Mumbai Undercity. I like reading about places I’ve been or would like to go. I also have been reading some of the excerpts from an international thriller novel a friend of mine is working on publishing – can’t wait to see that in print.
Ok, just one last question. If you could have dinner with anyone, alive or dead, who would you pick and why?
That is a really tough question. Can I just throw a party?! I’d love to meet famous women who have made a difference – like Aung San Suu Kyi or, closer to home, Hillary Clinton. They are role models for how you can help change the world. And then there are people who I’m just starting to hear about who are doing some cool things with social innovation – not as well known of course, but just as inspirational. Coming from a business background, I’m interested in hearing about new ways to solve the world’s problems.