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Keyword: rotavirus

By Rose Weeks

This article was originally published on Next Billion and is cross-posted here with permission. 

FOUR REASONS TO STEP UP PROGRESS ON REDUCING DIARRHEAL DISEASE

When my 6-week-old son got his first rotavirus vaccine dose last year, my husband and I were up what seemed like all night as he fussed and spat up. But even in my sleep-deprived state, I felt relieved to know that he would be protected from this life-threatening diarrheal disease.

Before the rotavirus vaccine was introduced in 2006, hundreds of children died from diarrheal disease in the United States. It was a devastating and preventable loss of life, but a tiny fraction of the 600,000 children estimated to die globally from diarrheal disease annually.

The just-published Pneumonia & Diarrhea Progress Report states that countries with the largest number of deaths from these diseases have not yet fully scaled up the use of available solutions to prevent and treat diarrhea, like rotavirus vaccine, oral rehydration solution (ORS) and breastfeeding.

Diarrhea still kills 1,000 per day: “It’s better, but it’s still horrific,” said Dr. Richard Guerrant, the director of the University of Virginia’s Center for Global Health, at last month’s annual meeting of the American Society of Tropical Medicine & Hygiene, a convening of thousands of public health scientists.

Beyond the death toll, incidence has barely waned at all. Children in low- and middle-income countries continue to experience about three episodes of diarrhea each year. Repeated cases of severe diarrhea, especially during important development stages in a child’s life, can have a lasting impact on physical and cognitive growth. Diarrhea can also make children more susceptible to death from other causes like pneumonia.

THE UNFINISHED AGENDA


ORS only reaches 1 of 3 children in need.
Children sick with severe diarrhea can be fully rehydrated with ORS – an inexpensive mixture of sugar, salt and safe water – within a few hours. ORS has saved an estimated 50 million lives worldwide. However, only one-third of children in low- and middle-income countries who need ORS get it.

Dr. Christopher Duggan, a professor in the Harvard School of Public Health who has studied ORS since the 1980s, spoke at the TropMed annual meeting about how social marketing is a critical tool to expand access. In Bangladesh, Social Marketing Company, an offshoot of PSI, has invested millions in marketing the use of ORS. Today, Bangladesh’s coverage for ORS is 77 percent, the best of the high-burden countries. Bangladesh also packages zinc supplements – another proven way to reduce the duration and severity of diarrheal episodes – with ORS. As a result, the country has attained higher coverage of zinc use than any other country surveyed.

Even when not fatal, diarrheal infections stunt children’s growth and cognitive development.
Malnutrition weakens immune systems, making children more vulnerable to infections like diarrhea. Diarrhea, in turn, prevents children from absorbing nutrients, contributing to malnutrition. This creates a viscous cycle. Children with a typical number of diarrhea cases per year suffer an average of 8-centimeter growth loss and a 10-point IQ loss, said Guerrant.

Making the situation worse, many caregivers withhold food from children and babies when they are suffering from diarrhea. It is very important to continue feeding children appropriate food during an episode of diarrhea, said Duggan.

Innovative market-based approaches to improving nutrition include mobile clinics, training community health workers and door-to-door sales of Sprinkles (sachets containing micronutrients). Some m-health programs like Totohealth in Kenya use SMS to monitor child development.

Vaccines against rotavirus, which causes 2 in 5 diarrheal deaths, are not reaching more than 90 million children or 70 percent of all infants worldwide. And not all children in the U.S. are vaccinated.
Rotavirus causes 40 percent of diarrhea hospitalizations and 200,000 deaths in children younger than 5 each year. Unlike other forms of diarrhea, rotavirus infections cannot be controlled by hygiene and sanitation alone.

Two rotavirus vaccines have been internationally licensed since 2006 and are used routinely in nearly 80 countries. Despite this, only 15 percent of the children in countries eligible for vaccine support from Gavi, the Vaccine Alliance – the world’s poorest – have access to rotavirus vaccines.

Dr. Umesh Parashar, who leads the Centers for Disease Control and Prevention’s Enteric Viruses Epidemiology Team, said that the use of rotavirus vaccines in the U.S. has led to a striking decline in rotavirus-related hospitalizations. In some years, there are few cases observed. Yet, because coverage is still not routinely high, varying geographically from 59-88 percent, the accumulation of unvaccinated infants periodically leads to outbreaks.

Public health impact has been dramatic in low- and middle-income countries where rotavirus vaccines have been introduced. In Mexico, the vaccine led to a 50 percent decrease in diarrheal deaths in children younger than 5.

New rotavirus vaccines are being developed in emerging economies to expand supply and lower price, but may need more help to be available for other countries.
Dr. Duncan Steele of the Bill & Melinda Gates Foundation – now making headline-worthy investments in accelerating the introduction of rotavirus vaccine in low- and middle-income countries – discussed one bright spot on the horizon.

Companies in China, India, Indonesia and Vietnam are developing new vaccines with prices as low as U.S. $1 per dose for governments (such as Bharat Biotech’s ROTAVAC, which India is soon rolling out in four states). But there are not yet enough doses of these new vaccines to cover all children in the countries where they are being produced, much less the millions of children around the world who are in need of this vaccine.

THE TIME TO ACT IS NOW

“The main message is – we are not winning this fight,” Steele summarized, pointing to the need for greater advocacy to mobilize support for proven, low-cost diarrheal disease solutions such as ORS, zinc and dysentery treatment.

“The time to act is now,” urged Mathu Santosham, chair for the Rotavirus Organization of Technical Allies Council.

Fourteen of the 15 countries with the most deaths due to pneumonia and diarrhea are currently eligible for new vaccine support from Gavi, but five won’t be eligible for long and some have only months to seek funding for rotavirus vaccines. Most poor countries have yet to approach global targets for ORS and zinc use.

Regardless of their birthplace, all children should be protected from suffering, stunting and the risk of death from diarrheal disease.

Rose Weeks is the director of communications for the Center for American Indian Health at Johns Hopkins Bloomberg School of Public Health and secunded to the International Vaccine Access Center to support the ROTA Council project.

By Dr. Mathuram Santosham, Chair for the Rotavirus Organization of Technical Allies (ROTA) Council, Director of the Johns Hopkins Center for American Indian Health, and Senior Advisor for the International Vaccine Access Center (IVAC) at the Johns Hopkins University, where he is also a Professor of International Health and Pediatrics.

This article was originally published on Impatient Optimists and is cross-posted here with permission. 

In 1980, the first summer I worked on the White Mountain Apache reservation, a community of fewer than 10,000 people in Arizona, so many babies were dying of diarrhea that we buried one every week.

To combat this major problem, we trained community outreach workers to give oral rehydration solution (ORS)—a mixture of sugar, salt and safe water—to babies and young children sick with severe, dehydrating diarrhea. Over time the practice spread and diarrhea deaths in the community dropped to nearly zero.

Proven solutions like ORS, vaccines and better sanitation and hygiene have dramatically reduced childhood diarrhea deaths around the world—from 5 million deaths in 1980 to 600,000 today.

But it’s not just deaths we have to worry about. Illnesses are a major issue too. As the rate of diarrhea deaths have dramatically come down, incidence has barely decreased at all. Children continue to experience an average of three episodes of diarrhea each year. A case of severe diarrhea, especially during important development stages in a child’s life, can have a lasting impact on physical and cognitive growth. Diarrhea can also make children more susceptible to death from other causes like pneumonia.

Recently, at TropMed in Philadelphia, recent progress in global efforts to protect children from diarrhea was hailed and the unfinished agenda highlighted.

Here are four critical things we need to do to protect children from diarrhea:

1. Expand access to ORS.

Children sick with severe diarrhea can be fully rehydrated within a few hours when provided with ORS. However, only one-third of children in low- and middle-income countries who need ORS get it. 

2. Improve nutrition and be sure to feed children suffering from diarrhea to stop the vicious cycle of malnutrition and diarrhea.

Malnutrition weakens immune systems, making children more vulnerable to infections like diarrhea. Diarrhea, in turn, prevents children from absorbing nutrients, contributing to malnutrition. This creates a vicious cycle. Because of malnutrition, one in five children worldwide is moderately to severely stunted. Children with two to three diarrheal disease infections a year suffer an average of 8 cm growth loss and a 10 IQ point loss.

Making the situation worse, many caregivers withhold food from children and babies when they are suffering from diarrhea. It is very important to continue feeding children appropriate food during an episode of diarrhea.  

3. Vaccinate all children against rotavirus, the leading cause of severe and deadly diarrhea.

Rotavirus causes 40% of diarrhea hospitalizations—and 200,000 deaths in children under 5 each year. Unlike other forms of diarrhea, rotavirus infections cannot be controlled by hygiene and sanitation alone. Vaccines are essential to prevention.

Two rotavirus vaccines are available and have been internationally licensed since 2006. These vaccines are currently used in the national immunization programs of nearly 80 countries. Despite this, only 15 % of the children in Gavi countries—the world’s poorest—have access to this life saving vaccine. Even in countries where rotavirus vaccines are used, the poorest children often do not get vaccinated.         

In the US, use of rotavirus vaccines led to a striking decline in rotavirus-related hospitalizations. In some years, there are almost no cases observed. Yet because coverage is still not routinely high (it’s varies geographically from 59-88% now), the accumulation of unvaccinated infants periodically leads to outbreaks. In the US, rotavirus vaccine coverage must be improved.

Worldwide, more than 90 million children still don’t have access to rotavirus vaccines. In countries where the most diarrhea deaths occur, almost none have introduced the rotavirus vaccine, despite considerable evidence of its public health impact, cost saving potential and the prospect of introduction support from Gavi, the Vaccine Alliance

Public health impact has been dramatic in low- and middle-income countries where rotavirus vaccines have been introduced. In Mexico, the vaccine led to a decrease by 50% in diarrheal deaths in children under 5.

Countries that do not already include the rotavirus vaccine in their national immunization program should consider the striking public health and economic benefits and take steps to introduce it as soon as possible. Countries that do, should work to ensure good coverage.  

4. Develop new, low-cost rotavirus vaccines to help reach all children. 

New rotavirus vaccines are in the pipeline and could help to accelerate coverage. Companies in China, India, Indonesia and Vietnam are developing new vaccines with prices as low as US$1.00 per dose for governments (such as Bharat Biotech’s ROTAVAC, which India is rolling out soon in four states). There are not yet enough doses of these new vaccines to cover all children in the countries where they are being produced, much less the millions of children around the world who are in need of this vaccine. Yet with new product licensures expected as soon as 2017, the product landscape could be quite different very soon. 

One thousand children per day still die from diarrhea—a preventable tragedy. We’ve made progress, but we can do much better.

As Nobel Laurate Gabriela Mistral said:

"We are guilty of many errors and many faults, but our worst crime is abandoning the children, neglecting the fountain of life. Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made, and his senses are being developed. To him we cannot answer ‘Tomorrow,’ his name is today.”

The Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea goal is to reduce mortality from diarrhea in children under 5 to fewer than 1 per 1,000 live births. This is a very ambitious goal but we know it is possible as long as the public health community can work together and garner political support. We need to make it happen.

To learn more about how you can get involved, visit this page.

This article was originally published on Global Health Now and is cross-posted here with permission.

By: Dr. Mathuram Santosham

ChildUPIndia
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.

MS_RotaSymp2014

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.

The Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD) was launched last month. Now this week we’ve learned that a new rotavirus vaccine from India, Bharat Biotech‘s ROTAVAC, looks promising, and The Lancet featured results from the Global Enteric Multi-Center Study or GEMS, which offers a comprehensive look at the causes of diarrhea in children, such as rotavirus. In light of this recent news and its impact on efforts to prevent and treat diarrheal disease, especially rotavirus, we sat down with Mathu Santosham, MD, MPH. Dr. Santosham co-chairs the ROTA Council and also chaired the Data Safety and Monitoring Board for the ROTAVAC trial established to protect the participating infants’ rights and needs during the trial.

Why is all of this recent news important for children?

Santosham

Mathu Santosham, MD, MPH

We know that pneumonia and diarrhea are the leading killers of children under 5 worldwide, and we know that we need an integrated approach that uses all proven tools to tackle these two illnesses and prevent unnecessary suffering and death. GAPPD is important because it provides a framework, designed to inform global and national programs and policies, for integrating efforts against these two child killers. It sets ambitious but achievable goals including reducing under-five pneumonia and diarrhea deaths to 3 per 1,000 live births and 1 per 1,000 live births, respectively. A big part of the strategy for tackling both illnesses is vaccination.

For diarrhea, we know rotavirus – a pathogen for which there is a vaccine – is the leading cause of severe diarrhea among infants and children. In fact, the active surveillance results announced from the seven sites in GEMS reaffirmed this understanding, and offered important insights that will help better target interventions to the pathogens like rotavirus that are causing the most diarrhea. We also know that rotavirus contributes significantly to child mortality. According to the most recent estimates, more than 450,000 children died from rotavirus diarrhea in 2008. Rotavirus vaccine is critical to protecting children from rotavirus and preventing illness and death.

There are currently two licensed rotavirus vaccines, and they are saving lives and improving health today in the countries where they are in use. Having an additional vaccine from an Indian manufacturer will expand the market, which will offer more options to protect children in India and around the world. If licensed, Bharat has committed to offering the initial frozen formulation at $1 per dose, which will increase market competition for countries and organizations procuring vaccine. Also, it is especially encouraging to see India making so much progress toward a vaccine because nearly one-quarter of rotavirus deaths occur in India.

Why is rotavirus such a large concern?

Rotavirus is highly contagious and can last for long periods of times on hands and surfaces. It is not adequately prevented by proper hygiene or improvements in water and sanitation, like other pathogens that cause diarrhea. So even children in developed countries are susceptible to contracting rotavirus. In fact, nearly every child will be infected at least once by the age of 5. Once infected, a child often experiences symptoms that include fever, vomiting, and diarrhea. In developed countries where access to care is more reliable, children are unlikely to die from this infection, but in developing countries, children are less likely to have quick access to oral rehydration, making them at risk to suffer severe dehydration. This can lead to hospitalization and even death. In addition, children who suffer from malnutrition are more vulnerable to diarrhea, and diarrhea in turn worsens their malnutrition, resulting in a vicious cycle. For these reasons, rotavirus is a concern worldwide, but especially in developing countries.

What can we do about rotavirus?

Rotavirus cannot be treated with antibiotics or other drugs. However, its symptoms can be alleviated by prompt use of oral rehydration therapy (ORT), which includes home available fluids, oral rehydration salts (ORS), and, in cases of severe dehydration, IV fluids. ORT can effectively treat most rotavirus infections, but when the treatment is received too late, rotavirus can be deadly. In India, only about 4 in 10 children receive ORT when they have diarrhea. Vaccination, on the other hand, can actually prevent rotavirus diarrhea from happening in the first place. The two currently licensed vaccines, Rotarix and RotaTeq, have been demonstrated to be safe and effective and have been introduced in more than 45 countries. When combined with ORT, zinc supplementation, breastfeeding, and improvements in nutrition, hygiene, and water quality, vaccines contribute to the comprehensive approach required to effectively prevent severe illness and deaths caused by rotavirus diarrhea. 

What is ROTA Council doing about this problem?

ROTA_Council_2012

Dr. Santosham with other members of the ROTA Council at the International Rotavirus Symposium in Bangkok, September 2012.

The ROTA Council, which I co-chair with Dr. Ciro de Quadros of Sabin Vaccine Institute, is a dedicated team of technical experts with the mission of saving children’s lives by accelerating the introduction of rotavirus vaccines. We work at the global and country level to ensure that policy makers have the latest evidence-based information to inform their decisions about introducing and scaling up rotavirus vaccines as part of broader diarrhea control efforts. At the same time, many of our Council members are on the frontlines of research, conducting the studies needed to demonstrate vaccine efficacy, safety, and impact. We are pleased to see that more than 45 countries have introduced rotavirus vaccines, but many more are still leaving their children unprotected, particularly in Asia, where countries have been slow to introduce the vaccine.

Why should India and other low- and middle-income countries introduce rotavirus vaccine?

Rotavirus diarrhea is a ubiquitous problem that can have some very serious consequences. In India, and other countries where access to care can be quite unequal, prevention becomes even more critical. If left untreated, rotavirus infection can lead to unnecessary illness, hospitalization, and even death, which is not only concerning from a health standpoint, but also takes a very serious toll from a social and economic standpoint. Hospitalization for one child with rotavirus costs nearly the entire amount of an average Indian household’s spending in a month. Diarrhea related healthcare needs are also costly for the country and stretch its already burdened state healthcare system. Beyond direct costs, vaccination could avoid productivity losses and help children grow into healthy, educated, productive adults.

The vaccine has the potential to make a big difference in the lives of families around the developing world. In India alone, we could prevent tens of thousands of deaths, not to mention nearly 300,000 hospitalizations and more than 300,000 doctor visits, which amounts to savings of over US$20 million in medical costs.

Based on your experiences, what is your hope for India and the rotavirus vaccination?

As a medical student in India in the 60s I saw children dying of diarrhea every day. Over the years, we were fortunate enough to develop powerful treatments like ORT, which helped to reduce the number of diarrheal deaths per year from 5 million in 1980 to less than a million now. However, more than 700,000 children continue to die from diarrhea annually because they don’t get the necessary treatment on time. Rotavirus is the leading cause of these diarrheal deaths, and it is a tragedy to see a child die from rotavirus when we have such a powerful weapon to combat this disease. It is my sincere hope that every child in India will soon have access to this life-saving vaccine.

 

Mathuram Santosham, MD, MPH, is Co-Chair of the ROTA Council and Professor of Pediatrics and International Health at Johns Hopkins University. He also serves as Director of the Center for American Indian Health, Director of the International Center for Maternal and Neonatal Health, and a Senior Advisor at IVAC.