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Keyword: pcv

This post originally appeared on the Nigeria Health Watch and is cross-posted here with permission.

By Chizoba Wonodi

Nigeria launched the introduction of the pneumococcal conjugate vaccine (PCV)into its childhood immunization schedule in Lokoja, on December 22nd 2014. PCV prevents one of the deadliest bacterial causes of pneumonia, meningitis, blood infections and middle ear infections in children. Before now, only parents with the means could afford to vaccinate their children for thousands of naira in private clinics. But now, government is offering it for free to all kids. This is a big deal, so get excited!


 Launch of PCV Vaccination in Lokoja

A journey that began 6 years ago has finally come to a successful end. But it was not an easy ride. As I think about the road to this introduction, I remember all the twists and turns along the way and marvel at the tenacity and perseverance of the chief actors in this story.

In 2008, I was working for a Johns Hopkins project called PneumoAdip, which was set up to accelerate the introduction of PCV into African and Asian countries. You may wonder why anyone needs a project to do that, right? Well, it turns out that having a vaccine that works is not enough to get countries to use it, unless the vaccine is for Ebola. I bet countries will scramble for an Ebola vaccine, if it comes. But then most diseases are not like Ebola. For more silent diseases like pneumonia, it takes concerted effort to make the decision makers recognize the burden of the disease, the value of the vaccine and the actions to take on it. For example, it took Nigeria 21 years to adopt the Haemophilus Influenza b (Hib) vaccine into our routine system. The first country to use Hib vaccine in their national program started in 1991, we started 2012.

I remember sitting in the Premier Hotel Ibadan during the 39th Annual General and Scientific Conference of the Paediatric Association of Nigeria (PANCONF) in January 2008. The halls were packed, the place was buzzing, the energy was infectious, pediatricians were milling around discussing how to save babies. I had come from Baltimore to field test a pneumonia diagnostic tool and discuss the prospect of Nigeria introducing PCV into the national immunization program.

At one of the session breaks, I cornered Dr. Abanida, then Director of Immunization at NPHCDA and asked him, “Doc, when are we going to introduce penta and PCV?” “Very soon” he replied, “We will apply for both vaccines this year”. This was an unexpected and pleasant surprise. I had predicted he would commit to only penta, but PCV as well? That was great. You see, it was no coincidence that we were coming late to the penta party when countries like Kenya had introduced the vaccine 8 year before. As a country, we had been preoccupied with battling polio, especially after the major polio vaccine rejection of 2004. In addition, our systems were weak. Indeed, before 2005, we would not have been able to apply for Gavi support for new vaccines even our immunization coverage was less than 50%, less than the required threshold. To get Gavi’s help, countries have to meet certain eligibility criteria and they have to formally apply and be approved for support.

Just as Dr. Abanida had declared, in April 2008, Nigeria tendered their first Gavi application for penta and PCV introduction support. In June 2008, the reviewers granted the application a conditional approval.

Disappointed but not deterred, in September 2008, the new vaccine application team led by Dr. Oteri, then Gavi desk officer at NPHCDA, responded to the conditions and queries from Gavi. But the second submission was rejected and the country was asked to re-apply.

Three things then happened that delayed the process for the next two and half years. First, Gavi suspended all new vaccine applications due to internal processes and funding constraints. No country could apply for new vaccine support in 2009. Second, Gavi revised their new vaccine application policy, now requiring an immunization coverage rate of at least 70% instead of 50%. Third, Nigeria’s vaccine coverage dropped below 50% to 42% according to WHO-UNICEF estimate released in June 2010. This new drop caused Dr. Dorothy Esangbedo, then the President of the Pediatric Association of Nigeria, to lament bitterly and call for stronger action to shore up routine immunization.

Under the new policy and with the lower coverage, Nigeria could not re-apply in 2010. In fact, a workshop in August 2010 convened by NPHCDA to develop the third submission was truncated by the twin news that our coverage rate had dropped and Gavi coverage requirement had increased.

When Gavi began revising their policy, there had been talk and expectation in some quarters that countries such as Nigeria, who were already in the application process before the policy change, would be “grandfathered in”. That did not pan out. To help matters, Gavi delayed the implementation of the new coverage requirement by one year, which left Nigeria with one window of opportunity to apply in May 2011.

But there was one more hurdle to scale. Coverage estimates for 2010 had to be 50% or better. The National Immunization Coverage Survey (NICS), showed coverage to be 71% for 2010, but Gavi only recognizes the WHO/UNICEF estimates, which was still 42% and would only be updated in July. Nigeria needed the updated estimates to apply in May. The update would be two months late. What to do?

The emails and phone calls started going back and forth advocating for a solution. At IVAC we pushed for different options: allow Nigeria use the NICS to apply, allow a phased introduction, so that states that meet the coverage criteria can be supported to introduce the vaccine, while effort be made to raise coverage in the other states. Dr. Mohammad Ali Pate, then Minister of State for Health, was very vocal in his advocacy to find a solution. Eventually and exceptionally, Gavi allowed Nigeria to apply for penta and PCV in May 2011. Then in July 2011, penta was approved and PCV was conditionally approved. All decisions were subject to the 2010 WHO/UNICEF DTP3 coverage estimates being >50%.

After the July 2011 conditional approval for PCV, Nigeria worked on responding to the conditions attached to the approval by strengthening the cold chain system. Then, 15 months later, in October 2012, Gavi gave the final approval for a phased roll out of PCV to begin in 2013. However, due to global supply constraints and other operational issues such as strikes in the Nigerian health sector, the first child could not be vaccinated till December 2014.

I didn’t go for the launch, but my colleagues went, and it was gratifying to see the culmination of everyone’s effort. Big thanks should go to the NPHCDA, GaviUNICEFWHOPediatric Association of NigeriaCHAI and all other groups who have pushed hard to see this happen.


First Nigerian Child to receive the Free Pneumococcal Conjugate Vaccine

As I look at the grainy picture of baby Collins, who is the first child to be vaccinated, cry out in pain from the shots of the first PCV vaccination, I wish I could tell him,

“Baby, don’t cry, laugh instead, even though that injection is painful. You are getting a shot a life. Something that babies before you did not get, but thankfully those after you will receive. If we are able to immunize 87% of your fellow babies every year with this vaccine, we can save about 200,000 lives by 2020. Isn’t that something to laugh or even rejoice about? Yes indeed, it is cause for celebration. I only wish it didn’t take six long years for this to happen. Think of all the babies we could have saved in that time. Anyway, you are too young to understand all this. After all, what do you know? You are just a baby. You probably just want to suck you mother’s breast right now, forget all this noise and go to sleep. So I’ll let you be.”


Dr. Chizoba Wonodi (MBBS, MPH, DrPH), 
Nigeria Country Programs Lead, Johns Hopkins International Vaccine Access Centre,  
Advisor, Saving One Million Lives Initiative,  
Advisor, Gavi’s Strategic Demand Forecast for vaccines.

By  Dr. Daniel Feiken

“My lovely girl is gone.  My lovely girl is gone.  My lovely girl is gone,” the young woman wailed.  A clutch of family members supported her limp body, her immobile feet dragging across the floor as if she were levitating.  A crowd behind the waiting area barrier watched the spectacle with stony faces.  People in the crowd held up signs – “Karibu Kenya – Micato Safaris,” “Mt. Holden Ministries – Kenya Summer Tour, July 2011,” “Mr. V. Patel” – momentarily lapsing in their scanning of the faces of the arrivals for a smile of acknowledgment. The woman, still chanting her lugubrious refrain, was ushered out of the Arrivals Hall at the Kenyatta International Airport into the cool darkness of the Nairobi night.

It was a fitting welcome mat for my return to Kenya. I left a year ago after having lived here for six years.  Although I never got rid of the deep gnaw inside that scenes like this evoked, I came to expect their regular interruptions in my daily life. The outer layers of life are peeled away here, exposing a raw core of existence that is mostly swaddled in America.  Violence, poverty, illness and especially death, lurk everywhere. In the villages, in the urban slums, on the roads, in the wild bush. Death is not an abstract notion here. Nobody writes books about it. During my time here, I knew few Kenyans who did not suffer an unexpected or premature death in their families. Children bore a disproportionate burden of these deaths. Still in Kenya, one in ten children die before their 5th birthday; in some areas, it’s two in ten. So the story that quickly dovetailed in my mind when I saw the distraught young woman in the airport was that she had been working abroad, sending money back for her family, including her baby daughter, who she had just been informed had died from a sudden illness. In my mind, that illness was pneumonia, because pneumonia is one of the leading causes of child death in Kenya and because pneumonia is the disease that I work on. The most likely culprit in my story was pneumococcus, the bacteria that causes the most pneumonia deaths in the world.

I recently watched the spiffy graphical display put together by Hans Rosling, demography’s Swedish conjurer, of the progress that has been made in global child mortality over the last century. On an animated graph, multi-colored and multi-sized spheres, depicting countries by continent and size, slide their way from the lower left quadrant (representing high child mortality) to the upper right quadrant (representing low child mortality) over the last century as their child mortality rates drop. Rosling relishes pointing out how the cluster of Asian spheres, mired in the lower left for the first few decades of the 20th century, have in the past half century sprinted towards the upper right, now nipping at the heels of North America and Europe.  Improvements in health, he points out, generally precede improvements in economies. The flight of the Asian tigers has left a lonely club of mostly African countries at the bottom. Watching the graphical display in motion several times, another feature of the display’s kinetics strikes me – individual countries don’t just move gradually in one direction, but rather bounce up and down in spikes, their trajectory looking more like a seismic reading than a smooth vector. Some of these annual spikes have obvious explanations – most countries plummet precipitously with the 1918 influenza epidemic and during World War II. What is less clear is why some countries seem to leap up when they do. I suspect that these are more idiosyncratic, likely related to individual government policies, or perhaps to the advent of public health interventions. If it is the latter, then 2011 could likely be one of those upward blips for Kenya.  

On February 14th of this year, the Ministry of Health of Kenya officially introduced the pneumococcal conjugate vaccine (PCV) – designed to protect young children from the most common cause of vaccine-preventable death - with support from GAVI and the Advanced Market Commitment (AMC), an innovative international financing mechanism making it possible for the world’s poorest countries to sustainably introduce the latest, most sophisticated pneumococcal vaccines. Kenya joined only a handful of other sub-Saharan African nations who have introduced PCV including South Africa, the Gambia and Rwanda.  The Kenyan Division of Immunization Services had been waiting for several years for this day – securing nods of approval from the Ministers of Health and Finance, expanding cold chain capacity and training immunization staff on the intricacies of administration of this new vaccine. At the official launch of PCV in Kenya, there was a well-deserved, shiny moment of pomp, congratulatory handshakes and high-minded speeches. But beyond that, the introduction happened smoothly and efficiently, without fanfare, in the hundreds of immunization clinics scattered across this vast country.

The other day I went to one of those clinics at Lwak Mission Hospital, where I used to work in rural western Kenya. I like to go back to the field when I return to Kenya. The sights, sounds and smells of rural Africa reconnect me to the reasons I got into global public health in the first place. At Lwak Hospital, the benches were full of mothers waiting with their babies for their immunizations. I spoke to the male nurse who operated the clinic. He excitedly explained how the demand has been fantastic, with mothers bringing in babies even beyond the indicated age for vaccination (i.e. 6 weeks - 11 months) to inquire if they could get the “pneumonia” vaccine for their babies. He showed me the supplemental sticker that had been designed to put on the immunization card to indicate the date and dose of PCV administered. Then he reached into the cool box and brought out the two-dose vial of PCV.   Knowing something about the vaccine’s complicated history – the technological sophistication of its design, the intricacies of its financing hashed out among high-level officials in meeting rooms in Geneva, London and Rome and the politics of its licensing – the tangibility of that diminutive vial in a cheap plastic cooler in a remote African village startled me somewhat. Yet, there it was, about to be injected into the chubby thighs of the babies waiting in the queue. 

This unassuming scene, it dawned on me, held the story and the promise of a sudden upward tick for the Kenyan orb on Hans Rosling’s graphic. That rise, if the epidemiology of pneumococcal disease in Kenya goes as expected from previous experience with PCV, will be what the world will see and remember about the vaccine’s introduction in Kenya. But the unseen story, perhaps, will be a quieter one. It will hopefully be the quiet of future arrivals at the airport in Nairobi.

Dr. Daniel Feiken is the Director of Epidemiology at IVAC.