By Kelly Healy
When I first traveled to India as part of my master of public health program,
Participants at Hib Symposium in Odisha, India in July.
I left feeling inspired to do something to help India’s children and families. Less than a year later, now at The Johns Hopkins University as a new research associate for IVAC, I had the opportunity to return to India as part of a team working to accelerate vaccine introduction to reduce child deaths from pneumonia and diarrhea. While there, I was able to see in real terms the impact efforts by IVAC and its partners have had.
I traveled to Bhubaneswar, a “small” city, if only by Indian standards, with a population of less than 900,000, that is the capital of Odisha. There, on July 9th, technical experts, government officials and other key stakeholders gathered for a one-day Hib Symposium, hosted by the policy unit of the National Institute of Immunology along with the Asian Institute of Public Health and designed to share data and experiences related to Hib disease and available interventions, including vaccines. While lesser known than pneumococcus, Hib or Haemophilus influenzae type b is a leading cause of pneumonia, the top killer of children in India and worldwide. It is also the leading cause of meningitis, which can result in death or serious neurological sequelae.
In 2010, nearly 400,000 deaths of Indian children under five were caused by pneumonia. While Hib vaccines have been proven to reduce cases of pneumonia and have been available for more than a decade, uptake has been slow in India especially in the public sector. However, that seems to be changing now, as more Indian states have expressed interest in adding Hib vaccines to their immunization programs, which would make them available at government clinics that reach the lower income populations who are at greater risk of dying from diseases like pneumonia and meningitis.
Media coverage of Hib Symposium.
Two states, Tamil Nadu and Kerala, have already introduced Hib vaccines (in the form of the pentavalent vaccine, which also protects against diphtheria, pertussis, tetanus and hepatitis B), and six more are slated to do so by the end of 2012. At the symposium, Ministry of Health and Family Welfare officials shared that eight more states have expressed interest. Judging from press coverage of the event, other states may not be far behind. All of this is great news for champions who have been advocating for Hib vaccines for several years, and a sign that Hib vaccine support may have reached a tipping point in India. The current momentum is driven by Indian technical experts and advocates like those who gathered in Bhubaneswar and other stakeholders at the center who recognize the important contribution of the vaccine. Our team at IVAC and its partner Global Health Strategies, Emerging Economies, are proud to offer technical assistance and opportunities to provide insight from other countries’ experiences and enable forums like the Hib Symposium.
However, many pieces of the puzzle still need to fall into place to gain widespread coverage of Hib vaccines among Indian children. In that light, state government representatives from Tamil Nadu and Kerala gave their peers at the symposium helpful insights from their rollouts, in particular highlighting the importance of pre-launch activities including evaluating the cold chain, training staff, establishing monitoring systems for adverse events and sensitizing policymakers and the media. They noted it was especially important to prepare stakeholders for the potential of adverse events following immunizations (AEFIs). One child died in Kerala after receiving the pentavalent vaccine, but thanks to sensitization efforts for government officials and a swift and clear response to the media, the state was able to quickly confirm the death was not caused by the vaccine and avoid derailment of the vaccine rollout. With careful preparation, Kerala and Tamil Nadu were able to carry out smooth launches and vaccinate more than 600,000 children in the two states combined through June.
I am excited to join the team here at IVAC at a time of such promise for India and look forward to seeing more progress in the coming months and years.
Kelly Healy, MPH, is a Research Associate at IVAC.
By Geoff Kahn
I must admit, I’m still fairly new to IVAC and to the kind of work we do here. A year and a half ago I worked in a lab, and the only contact I had with the outside world was when the FedEx delivery man would drop off a batch of new samples. Now I collaborate with doctors and other scientists halfway across the world. Specifically, I work in India, and I’ll tell you that at least as far as public health is concerned, 2012 is off to a good start:
On January 13 India celebrated one year without a new polio case; the introduction of the Hib-containing pentavalent vaccine that was launched in two states on December 14 and 17, 2011 continues unabated; and this month a hospital in Chennai will begin using a new, state-of-the-art real-time PCR machine to examine the causes of childhood meningitis with greater precision than ever before. While not as prevalent an illness as pneumonia or diarrhea, meningitis is nevertheless a fearsome disease due to its high mortality rate even in settings with advanced healthcare and its propensity for leaving up to a third of survivors with permanent disabilities, including deafness, mental retardation and seizure disorders. It is also linked inexorably with the more widespread pneumonia, as several bacteria species, notably Hib and pneumococcus, are leading causes of both diseases. The Institute of Child Health and Hospital for Children in Chennai, Tamil Nadu, is one of several sites in India where IVAC has been providing technical assistance to ICH to conduct surveillance of childhood meningitis. Their new PCR machine will enable scientists and doctors to test for over 10 different species of bacteria and viruses with greater sensitivity, leading to improved understanding of the causes, and therefore the means to combat, childhood meningitis in India.
But, to me, this machine is as much a symbol as it is a tool. It is a symbol of what is possible when local dedication, technical expertise, and international support come together. See the transformation that has been wrought:
Left: Not terrible, but also not much more than a box: cluttered space, no laminar air flow or UV lamps to keep things sterile. Right: That’s the new PCR machine in white, and yes, it is so fancy that it requires its own dedicated computer.
As impressive as it is, one is sobered by the realization that with success comes raised expectations. This hospital in India now possesses technology on par with any machine to be found at the CDC in Atlanta; it possesses scientists trained to use that technology, and it already possesses a commitment from the state government to take over funding the PCR work in 2013, once the support from IVAC ends. As advances like new machines, new vaccines, the fall of polio are made, the shortfalls - maternal and <5 mortality rates that are currently trending to fall short of MDG goals, malnutrition that runs rampant, gender equity that remains elusive - become less and less tenable. It is great that India is making the advances that it is, and it has been wonderful to work with the doctors and researchers in Chennai and elsewhere, but we (IVAC, the public health community, perhaps you, dear reader?) must always be wary of stopping too long to rest on our laurels. It has been my pleasure to share the accomplishment of our partners in Chennai, but now, if you will excuse me, it’s time to get back to work.
Geoff Kahn is a Research Associate at IVAC.
By Lois Privor-Dumm
This is a moment we have been cautiously optimistic about. Was today going to finally be the day? Friday the 13th is not an unlucky day this year – it is the day that India has gone one year without a single new case of poliovirus! Every time I look out the window as I’m driving around India, I witness the all-too-common sight of someone suffering the debilitating effects of the disease. That image is a reminder about how horrible this disease is and that polio’s impact is not just on the individual, but a whole nation.
A man who contracted polio walks on crutches in the village of Kosi, 113 miles from Patna, India. Photo by Altaf Qadri / AP.
The efforts to stop this disease in India have been dramatic and it has been a roller coaster with significant ups and downs. After 741 new cases in 2009, there were only 42 in 2010 – the country was almost there. And then in 2011, there was just a single new case in 18-month old named Rukhsar from West Bengal. It was a heartbreaking occurrence, but efforts persevered.
I am struck by the level of effort committed to this goal: government, civil society and international organizations including WHO, the National Polio Surveillance Project (NPSP) based in Delhi, UNICEF, CDC and Rotary are all laser-focused on making sure that kids even in the hardest to reach places were immunized. The Bill & Melinda Gates Foundation is also instrumental in these efforts. It was no easy feat, as we’ve seen in other polio-endemic countries including Nigeria, Pakistan and Afghanistan. India was considered one of the toughest countries to tackle, making this effort all the more impressive.
|History of Polio Case Numbers in India|
The infrastructure requires an enormous amount of coordination with stakeholders who were not part of the government or its partners. Civil society, including community and religious leaders, NGOs and others all needed to be engaged. The outcome of polio eradication efforts is not just the achievement of interrupting transmission, but the commitment that is gained by those involved in disease prevention efforts. I don’t work directly on polio, but I recognize the benefits of building an understanding of the value of vaccines, creating a system that can handle the supply chain, monitoring and evaluation and constant communication. On a recent GAVI consultation visit to India, I was very happy to hear that the discussion was about how we can leverage the infrastructure created by the polio efforts.
It is important that we learn the lessons from polio and leverage the best practices, not only in India, but in other large countries like Nigeria, where stopping Polio is also within reach. One of the biggest lessons is that there are a lot of stakeholders that contribute to a successful vaccine program – it takes a village. The government plays a big role, but it is the community, that will directly determine success.
Building an understanding of what can be achieved, and helping to implement the strategies that can lead to that success, are ways that the IVAC team is privileged make contributions. We are all working towards the goal of improved health for people in countries like India and Nigeria. Today’s milestone inspires others to act in ways that can help not only polio eradication efforts, but disease prevention and control efforts more broadly. One year without a new case of polio in India is an important milestone, but as we continue to make great strides around the world, our best years are ahead of us.
Lois Privor-Dumm is the Director of Alliances and Information at IVAC.
By Dr. Mathu Santosham
The first baby to be vaccinated today is a young girl named Ardra. Pentavalent vaccine launches were organised in all the 14 districts of Kerala today. About 500 to 600 babies were vaccinated per district. Photo courtesy of Mercy Ahun.
As a pediatrician who has dealt with Haemophilus influenzae type b (Hib) disease for over 40 years, it is heartening to see that the Hib vaccine will soon be available to the poorest children in at least two states in India.
I have seen the devastating consequences of Hib pneumonia and meningitis - Hib is estimated to cause 20% of all severe pneumonias in children. If untreated or if treatment is delayed, there is considerable risk of the child dying. Hib vaccines have been available in affluent countries for over 20 years. They have also been available for children from affluent families in India for several years, but until recently have not been available to the poorest children. Unfortunately, it is the poorest children who are at highest risk for death from this disease because of poor access to health care. It is wonderful to know that at least some of the poor children in India will soon have access to this vaccine.
In addition to pneumonia, Hib also causes meningitis. As a pediatrician, I have cared for many children with this disease. Prior to the availability of Hib vaccines, meningitis was one of the diseases feared most by pediatricians in the western world. In addition to causing death in up to 50% of infants with the disease, meningitis can cause severe neurological problems such as paralysis, deafness, and blindness in approximately 40% of cases. The consequences of meningitis can take a major toll on the social and financial wellbeing of the child as well as the family.
The Government of India has many competing priorities to consider in allocating money for health care of the over 26 million children who are born each year. It is commendable that the Indian Government has made the prevention of this dreadful disease a major priority through the use of the Hib vaccine. It is my sincere hope that this vaccine will soon be available to all children in India.
Dr. Mathu Santosham is the Director of the Center for American Indian Health