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.
By Dagna Constenla, Gatien de Broucker, Jorge Martin del Campo and Alexandra Greenberg, IVAC at Johns Hopkins University
This article was originally published on the Dengue Vaccine Initiative's blog and is cross-posted here with permission. IVAC is a member of the Dengue Vaccine Initiative (DVI).
The successful introduction of a vaccine in affected countries depends heavily on issues such as supply constraints, potential demand, and the impact of policy decisions on future demand and supply. Strategic demand forecasts (SDFs) play a central role in enabling vaccine suppliers, donors, and country-level stakeholders to make informed decisions about vaccine supply, financing, and adoption. In recent years, Accelerated Development and Introduction Plans (ADIPs) have used strategic demand forecasts to adjust market forces for the purpose of accelerating access to new vaccines in countries where they are needed the most.
Our team at the International Vaccine Access Center at Johns Hopkins University has developed several models to estimate the potential demand of dengue vaccine and the costs associated with dengue introduction programs, enabling vaccine suppliers, donors, and country-level stakeholders to make informed decisions about vaccine supply, financing, and adoption. These models have been developed with specific price and coverage assumptions for a variety of target ages and regions.
For the next phase of our project, we will quantify the potential demand for dengue vaccines in Latin America, specifically Mexico, Colombia, Honduras, Paraguay, El Salvador and Peru, taking into account the different scenarios envisioned by each country. Using advanced economic modeling, we aim to determine which factors would drive dengue vaccine demand in these countries.
Building off of our team’s current work on a similar model in Brazil, our team will develop SDF models in collaboration with the Ministries of Health in Mexico, Colombia, Honduras, Paraguay, El Salvador and Peru. While we already have access to relevant information in some of the countries in the region, this collaborative work is essential to ensure that the outputs of the model are relevant and integrated in the decision-making process for each country of interest.
Approaching six different countries at the same time brings many challenges in forecasting the potential demand of the vaccine. Each country has unique characteristics that impact the way vaccine introduction decisions are made. Differing geographical specificities, population demographics, health systems and political infrastructure within countries are good examples.
While strategic demand forecasts can be powerful communication tools, they have certain limitations. SDF depends on the availability of vital pieces of information from stakeholders, namely in-country policy makers, industry, and global donors. Getting information from one stakeholder can be hard without the ability to rely on credible information from other relevant players. All stakeholders must participate with equal commitment towards providing timely and accurate data for the results of strategic demand forecasts to be valid. The lack of reliable information can also make it difficult to verify or test key assumptions made by disease modelers.
In addition to the potential absence of consistent and reliable information, it can be challenging to generalize across developing countries. Significant differences in low- and middle-income countries can make operating conditions vastly divergent on the ground, thereby making broad-based assumptions and generalizations ineffective. Economic and political conditions – such as the unequal distribution of resources and infrastructure, limited budgets, inadequate healthcare policies, and divergent political priorities – can vary substantially between countries, even within the same sub-region.
Lastly, unequal financial commitment from international and local donors makes it difficult to determine the price funders would be willing and able to pay for a vaccine. This is an especially crucial piece of information for low-income countries, which would be unable to introduce a new vaccine without significant support from outside funders. Without this vital information it is challenging to estimate the potential demand for a vaccine in any given market.
So far we are having fruitful discussions with highly positioned local stakeholders in each country including program heads, government officials and representatives at the national and state levels. Their response has surpassed our expectations: they are themselves working to engage new key actors in this discussion. Stakeholders are driven and committed to understanding this disease and to ensuring that a vaccine is introduced in the most efficient and beneficial way for every country.
This research will be critical for laying the groundwork so that countries in the Americas can establish a viable vaccine introduction plan, which can be immediately implemented following the introduction of a dengue vaccine.
By Rebecca Van Roy, Communications Officer, Vaccine Advocacy and Education at Sabin Vaccine Institute
This article was originally published on the Dengue Vaccine Initiative's blog and is cross-posted here with permission. IVAC is a member of the Dengue Vaccine Initiative. (DVI)
Earlier this year, DVI convened the Americas Dengue Prevention Board along with scientists, global health experts, mathematical modelers and representatives of dengue vaccine manufacturers to discuss updates in dengue vaccines and vaccine introduction. Held in Bogota at the Colombian National Institute of Health (Institituto Nacional de Salud – INS), the meeting was instrumental given the new available clinical trial data, particularly the results of the first Phase 3 trials ever completed for a dengue vaccine candidate. These results demonstrated that a safe and effective dengue vaccine is feasible.
A mosquito that costs over $2 billion
Dengue, caused by a small mosquito with black and white striped legs, is the most widespread vector-borne disease in the Americas. In 2013, cases and deaths nearly doubled those of previous years in the region. The southern cone reported the highest incidence rate of cases, but the Andean region reported the highest number of severe cases. The burden of dengue in the Americas has been estimated at more than $2 billion dollars, from hospitalization costs to loss of productivity, representing a significant threat to the wellbeing of the region.
A safe and effective vaccine can help reduce this threat. While the decision to introduce a dengue vaccine can only be driven at the country level, such decisions must be based on sound evidence. DVI Dengue Prevention Board Meetings seek to share and update existing dengue knowledge and identify gaps to ensure countries have scientific, objective data to make informed public health decisions proactively, before a vaccine becomes available.
An open forum to share dengue knowledge –-and its gaps
With this objective in mind, the meeting offered an open forum where participants revisited the minimum requirements for successfully launching a dengue vaccination program among other crucial dengue topics.
On the first day, they reviewed the status of dengue vaccine development with representatives of the manufacturers of the five vaccines in clinical trial (Butantan/NIH, GSK/Fiocruz/Walter Reed, Merck, Sanofi Pasteur and Takeda). They also discussed the applications of mathematical modeling for predicting the impacts of dengue vaccination.
On the second day, country representatives presented the current dengue situation in their homeland and perspectives on dengue vaccine introduction and use.
Finally, the meeting broke into groups to assess considerations for vaccine introduction. The Board then met separately to draw conclusions. The meeting ended with the closing remarks of the Colombian Ministry of Health, who highlighted the spread of dengue and the urgent need to stop it.
The Board noted the critical importance of linked disease surveillance and vaccination registries to monitor coverage and vaccine effectiveness, as well as monitoring for vaccine safety. They also urged the standardization of age groups and case definitions of dengue disease across countries in the region to enable comparisons. They called for further analyses to understand how a limited supply of vaccine might best be utilized in the first year(s) of vaccine introduction. They affirmed the importance of the Pan-American Health Organization (PAHO) for supporting vaccine introductions, particularly through activities such as issuing recommendations for laboratory-based disease surveillance in the region, with an aim of standardizing the diagnostic tests.
The table below summarizes these conclusions. For more detail we encourage you to read the full report here: “Development of Dengue Vaccines: A Review of the Status and Future Considerations.”
About Dengue Prevention Boards
In 2007, PDVI (Pediatric Dengue Vaccine Initiative—DVI’s precursor) established two regional Dengue Prevention Boards (DPBs) — one for Asia and one for the Americas. Members of the boards include medical and public health experts, opinion leaders and policy makers from countries in their respective regions. They meet once a year to advise on dengue surveillance, diagnostics, vaccine introduction and communications.
All reports on DPB meetings are published in the DVI website to inform dengue and global health stakeholders.
By Lois Privor-Dumm and Huma Khawar.
This article was originally published on Vaccineswork and is cross-posted here with permission.
Photo: UNICEF/PAK 2015/Asad Zaidi
In Nigeria and around the world, citizens, governments, doctors, and parents are fighting polio – and they’re winning. After nearly 30 years of polio eradication efforts, the end is in sight. In 1988, the year the World Health Assembly (WHA) resolved to eradicate polio, there were an estimated 350,000 polio cases globally; last year there were only 359, and this year cases so far are down by 75%.Misbau Lawan Didi leads a club he wants to eliminate. As president of the Polio Survivors Association, he is committed to not only end polio in Nigeria but to eradicate it from the planet. “We are determined,” he says, “to ensure that our members are no more.”
Polio has eluded us for decades. There have been plenty of starts and stops and lots of excitement about the polio eradication effort.
So what makes this time different?
Communities around the world are mobilizing, and momentum is building. Last month, one of the remaining three endemic countries, Nigeria, passed the one year mark without a single case of wild poliovirus. Once the final samples are tested and cleared, the World Health Organization should even be able to declare Nigeria a non-endemic country. Many thought it wouldn’t be done.
Now, Pakistan is embarking on one important step in its fight against polio and implementing the endgame strategy with introduction of the inactivated polio vaccine (IPV) across the country. It will take determination and sustained effort to ensure that it can be done – and with a decentralized health system, years of war, and continued threats against health workers, it will be no easy feat.
Step by step, progress is being made. We are on the brink of an unprecedented accomplishment. Yet, public health experts warn “the last mile” will be the hardest. Ending transmission of the virus in every country will take a focused effort and the use of every available tool against the disease. The Polio Eradication and Endgame Strategic Plan was developed to provide countries with a roadmap to help navigate this challenge. The plan calls on countries to make three important changes to their immunization efforts: 1) to introduce one dose of (IPV) into routine immunization schedules, 2) to strengthen routine immunization, and 3) to eventually withdraw oral polio vaccine (OPV).
The first phase of this plan, the introduction of IPV, is well underway. While there was initial concern over an accelerated timeline, communities and governments around the world have risen to the challenge. The introduction of IPV will be one of the fastest rollouts in history. Out of 126 oral polio vaccine (OPV) only using countries, 30 have now introduced. Today, on August 20th, Pakistan launches its nationwide rollout, which is no small feat. The significance of this rollout is monumental.
Photo: UNICEF/PAK 2015/Waseem Niaz
Introducing a new vaccine involves hundreds of technical and logistic details. There are budget considerations, procurement, storage and transport of vaccines, training of health workers, and communication with parents. Countries need to assess their systems and strengthen necessary components. In Nigeria, for example, communicating with the public was particularly important as skepticism about the polio vaccine halted past efforts. When Nigeria introduced the new polio vaccine in February of this year, community and religious leaders were active in the outreach to parents. In markets and in mosques, the public was told about the importance of immunization and using the IPV vaccine in the battle against polio. In February, when Nigeria became the first polio endemic country to introduce the vaccine, it was widely accepted by parents.
We are down to the last three polio endemic countries – Nigeria, Pakistan and Afghanistan – and now there is even greater hope. Last year, there were no new members of Nigeria’s Polio Survivors Association as the country did not have any cases of the disease. Work in Nigeria is far from over, but the effort is paying off: two more years without a reported case and Nigeria can be certified as polio free.
The same can be true in Pakistan and the other countries where communities are hard at work to protect their children and eradicate this virus. This time it really can be different. Pakistan, is your time now?
Lois Privor-Dumm is the Director of Policy Advocacy & Communication at IVAC at the Johns Hopkins Bloomberg School of Public Health. Huma Khawar is a freelance journalist and consultant based in Islamabad who works with stakeholders on the ground in Pakistan to advocate for new vaccines through the Vaccine Implementation Technical Advisory Consortium (VITAC), a project of the Gavi Alliance.
With the help of a long list of partners and supporters, IVAC has developed a portfolio of advocacy materials supporting IPV introduction, which can be found here. Inquiries can be directed to Lois Privor-Dumm at email@example.com.
By Dr. Anne von Gottberg, Respiratory and Meningeal Pathogens Research Unit, National Institute for Communicable Diseases
This article was originally published on www.vaccineswork.org and is cross-posted here with permission.
If you had looked at South Africa’s invasive pneumococcal disease (IPD) surveillance data before 2002, you would have never guessed that one day that data would land on the pages of the New England Journal of Medicine.
Even I thought such a feat was impossible. Surveillance for IPD was passive and patchy – certainly not the kind of data you could use to examine trends or measure impact. In 2002, experts in pneumonia and respiratory disease suggested that we completely revamp the system: start measuring antimicrobial resistance and serotypes, obtain clinical data from cases to explore risk factors for resistance. Although this was long before the pneumococcal conjugate vaccine (PCV) was introduced, we knew any investments we made in the surveillance system now would pay huge dividends later, and possibly allow us to measure the impact of PCV introduction.
An example of disease surveillance activities. Here, Noluthando Duma works in the lab. Photo: NICD.
Revamping a national surveillance system was not an easy task. Our institute managed the process - from employing surveillance staff throughout the country to collecting data - and we had many, many challenges. This project seemed so unusual, so impossible, that it was difficult to convince anyone to join us. We would interview surveillance officers at remote regional sites who wondered how they could report to a central office in Johannesburg, given that they had never even been there; they couldn’t imagine how such a big, unwieldy national program could ever work. We would answer their questions with what I hoped sounded like confidence, but the truth was that we were figuring out the answers as we went along.
Despite these human resource challenges, we charged ahead, but it was a slow-and-steady race. At our national surveillance officer and principle investigator meetings, we had to bring together key stakeholders to discuss the surveillance network. We had to get buy-in on the methods, the case definitions, the flow of data, and sharing of information, and then we had to hire staff to operationalize our ambitious plans. Many new hires had never been on an airplane before, and some had never seen the ocean – the surveillance network really made South Africa smaller, bringing people together in the “new South Africa” in ways that I could not have predicted. So we anxiously booked window seats, made time for quick excursions to the beach, and hoped for the best. And although we had our fair share of hiccups along the way, our small team continued to grow, the years passed, and we kept on finding ways to silence the naysayers!
Meanwhile, things did not stay still around us. The South African government suddenly found the political will to tackle the HIV/AIDS epidemic, and with a tremendous effort, the government and civil society rapidly improved care of HIV-infected pregnant women, HIV-infected children, and adults in general. With these sudden improvements in healthcare, IPD also changed, making it more difficult to attribute any declines to the vaccine, even with the new surveillance system. But through a series of discussions with local and international colleagues and friends, countless conference calls, and careful review of the data, it finally became possible to tell the story that was in the data, collected for so many years by our dedicated surveillance teams.
Colleague Kedibone Ndlangisa conducting lab work. Photo: NICD
Last week, as experts and decision makers gathered in Kenya to discuss the results of various PCV impact studies from across Africa – all showing significant reductions in pneumococcal disease after the introduction of the vaccine – I was reminded of how far we had come on our journey and the many lessons learned on our path.
By maintaining our slow-and-steady approach remembering to “ask a friend” when we were stumped, and above all continuing to plow on in the face of challenges, we were able to turn data that at first glance may have looked like a mess into a meaningful and robust assessment of the impact of PCV.
This study is part of the the Vaccine Implementation Technical Assistance Consortium (VITAC) - a collaboration of PATH, CDC, and IVAC - supports the achievement of the mission to save lives, prevent disease, and promote health through timely and equitable access to new and underused vaccines. VITAC is focused on accelerating the introduction and sustained use of vaccines by creating the evidence base, advocating for evidence-driven decision making, and establishing a platform for countries to assess the resources needed for sustained and optimal use of vaccines.