By Adam L. Cohen
The operator of a clean cookstove cooperative in Mulanje, Malawi. Photo by Matt Feldman / IVAC.
When I moved to South Africa a year and a half ago to work for the U.S. Centers for Disease Control and Prevention on surveillance for pneumonia and influenza, I didn’t realize how much pneumonia affects communities here. Most of the children in the hospital wards where I work are having trouble breathing, hospitalized with pneumonia. Pneumonia is the leading cause of death among children under five in South Africa and worldwide. Mothers want their children with pneumonia to get better, and public health policymakers want to do what they can to make their country as healthy as possible. But how can we help countries do this? There are multiple, proven interventions to prevent and treat pneumonia, but it can be difficult to get these interventions to the people who need them most. At the CDC, we set out to examine the opportunities presented by the delivery of preventive measures, such as childhood immunization, to explore practical approaches for integrating other interventions to treat and control pneumonia in children. Our complete findings are published in the Bulletin of the World Health Organization.
With so many existing methods of reducing the burden of childhood pneumonia, there are exciting opportunities to integrate multiple approaches to improving child health. But there are also many challenges. Most children have access to basic immunizations—could we use this to help protect the children of the world against pneumonia? Globally, many routine vaccination programs are strong, which means that huge strides could be made in pneumonia prevention and treatment by integrating interventions like pneumococcal and Hib vaccinations, zinc distribution, and caregiver education with routine immunizations.
Neither vaccination nor case management alone is enough to eliminate child pneumonia deaths, owing in part to the large number of bacteria and viruses that cause pneumonia. Other important interventions include caregiver education, referral to health care facilities during routine immunization visits, zinc supplements, HIV testing, and the promotion of health behaviors such as breastfeeding, proper nutrition, hand-washing with soap, and the reduction of indoor air pollution.
However, not all interventions are easily distributed, like cleaner burning but bulky cookstoves, and overburdening community heath workers could cause frail health systems to falter or break. There are few of us in the field of public health working to evaluate the integration of multiple interventions. Further, integration of service delivery would require coordination and cooperation across the entire range of donor organizations, NGOs, and governmental ministries.
To address these challenges, we must conduct small-scale studies that elucidate best practices and evaluate the impact of integration before scaling up to large national programs. This will help us empty the hospital wards in South Africa and worldwide.
Dr. Adam L. Cohen is the Influenza Program Director at Centers for Disease Control and Prevention in Pretoria, South Africa.
By Dr. Hope Johnson
Children in Phalombe, Malawi. Photo by Matt Feldman / IVAC.
Understanding the major causes of child mortality is essential to establish health priorities and improve the health of children globally. Over the past decade, WHO and UNICEF’s Child Health Epidemiology Reference Group (CHERG) has strived to meet this need by publishing national, regional, and global estimates of the causes of child mortality. This information has been crucial to the development of child health interventions and long-term child survival strategies.
Since CHERG’s first report, estimation methods and the quality and quantity of child mortality data reported by country vital registration systems have drastically improved. This week, a new CHERG report presents for the first time annual disease-specific time trends for causes of child mortality over the past decade.
The new data, published in The Lancet, show that child mortality fell by 2 million deaths, from 9.6 million to 7.6 million between 2000 and 2010. According to CHERG, declines in mortality over this period are likely due to improving socioeconomic factors and the successful implementation of child survival interventions in developing countries, particularly those targeting nutrition.
But what continues to claim the lives 7.6 million children around the world every year? Infectious diseases are the main culprits–responsible for 64% of all deaths in children under five. And notorious killers, pneumonia and diarrhea, remain important causes and together were responsible for more than 2 million deaths in 2010. Sadly, a striking 40% succumb within the first month of life most often due to complications related to preterm birth.
Despite the historical drop in mortality seen between 2000 and 2010, the current rate of mortality reduction is insufficient to achieve the fourth UN Millennium Development Goal (MDG4): reduce the child mortality rate by two-thirds, before 2015.
Rapid introduction and scale-up of existing child survival strategies focused on infectious and neonatal causes, particularly in high burden areas of Africa and southeast Asia, is critical for achievement of MDG4. There’s reason to hope, however, with the continued rollout of life saving vaccines for pneumococcal disease and rotavirus by GAVI Alliance and its partners at an unprecedented pace, and at a price low-income countries can afford. But vaccines alone won’t stop pneumonia and diarrhea–other proven interventions such as improved nutrition, appropriate antibiotic treatment, and breastfeeding are also essential elements in this fight.
This newest CHERG report provides a valuable picture of the current state of child mortality worldwide. The data will allow policy makers to prioritize introduction and scale-up of effective interventions to reduce child mortality. CHERG’s job, however, is not over: monitoring the evolving causes of child deaths will continue to be a crucial part of global efforts to erase the 7.6 million child deaths that still occur each year.
Dr. Hope Johnson is an Epidemiologist at IVAC.
cherg, unicef, who
By David R. Curry
Villagers line up to be vaccinated against Smallpox at an outdoor clinic, Côte d'Ivoire, 1970s. From the WHO Archives.
In February, 2012, I participated in the WHO Extraordinary SAGE meeting in Geneva, called to review the Global Vaccine Action Plan (GVAP) being developed by the Decade of Vaccines Collaboration (DoVC). On the flight back to the U.S., I was reflecting on the continuing challenge of identifying and scoping "game changers" in the GVAP to help realize the DoV’s ambitious vision:
The vision for the DoV is a world in which all individuals and communities enjoy lives free from vaccine-preventable diseases. Its mission is to extend, by 2020 and beyond, the full benefits of immunization to all people, regardless of where they are born, who they are, or where they live.
We need “game changers” because of the scale of the challenge, to be sure. But I was also reflecting on the history of global immunization strategies and that we have faced the same core challenges for generations.
Having arrived early for the SAGE meeting, I spent a day in the WHO Archives pursuing the broad question of when the WHO first considered anything like a global immunization strategy, and at least one other reference point for perspective. Two original documents caught my attention.
The first was a report from what appears to be the first expert consultation on this theme: the first session of the Expert Committee on Maternal and Child Health, Geneva, January 1949. The session title was Immunization Against Principal Communicable Diseases of Childhood - Plan for an International Program (WHO/MCH/5).
The meeting report surveys the then-current knowledge on immunization – informed by WWII – and includes a key recommendation for convening an "international expert conference on immunization procedures as soon as possible. This conference should bring together epidemiologists, paediatricians, heads of child-health services, and experts responsible for the preparation of vaccines in state and other official laboratories and institutes. The conference should discuss the use of the newer techniques for producing the more effective vaccines (e.g. pertussis vaccine) and plans for their widespread application in immunization programs..." The proposed conference was later convened as a result of a resolution adopted at the Second World Health Assembly.
But in the meeting report, the assessment of immunization and its challenges in 1949 (as thinking about an international program was just underway) was alarmingly "current":
"Where immunization programmes have failed, the main reasons for such failure have been 1) a false sense of security when the incidence of these diseases happened to be low, although the population has not yet been adequately immunized; 2) Lack of adequate health education of the public; 3) Insufficient information among the medical professions as regards new immunization procedures; 4) Reluctance to use auxiliary personnel for mass immunization; 6) Lack of appropriate immunization agents [vaccines]; and 7) Lack of appropriate legislation and funds for immunization programmes."
A companion recommendation was the release of a circular letter by WHO to all WHA members surveying "active immunization" programmes, including an inventory of which diseases and what age groups might be involved in either "advocated" or "compulsory" immunization, whether the country's programme was "assisted by an organized public information campaign," and whether the public is "generally eager for immunization, passive, or reluctant..."
The second reference point comes from a 1974 Consultation on the WHO Expanded Programme on Immunization held at Geneva (VIR/74.15), obviously very early in the EPI era. The report notes:
"...most diseases against which vaccines are available are still uncontrolled in virtually all developing countries. The principal problems are a) lack of trained personnel (and often the idea that only physicians or highly trained nurses should administer vaccines); b) use of complicated immunization schedules appropriate to developed countries but which do not recognize the local epidemiological and administrative realities of the developing world; c) the high cost of equipment and difficulties of maintenance of e.g. transport, refrigeration and jet injectors; d) the cost of many of the vaccines, and e) restrictions on the production of some vaccines because vaccine strains or methods have been patented."
Later in the report, two additional factors around "shortcomings in immunization activities" caught my attention: that “cost benefit and cost effectiveness analyses are either not appreciated by health planners and administrators, or have not been undertaken...” and that “illiteracy and poorly developed public information media result in the lack of public understanding of the need for immunization..."
Finally, this 20-page analysis concludes with a series of recommendations for the year ahead, asserting: "Immunization must be recognized as an essential and permanent programme for the control of communicable diseases and must be a primordial responsibility of the country concerned. The role of the WHO is to stimulate countries to set up immunization programmes and to assist them in doing so..."
These two reference points – from over 60 years ago and almost 40 years ago – are, in a sense, humbling. But they also are a fresh call-to-action. Now is the time to focus our energies and stretch our collective imagination to complete the GVAP with critical game changers, and boldly implement it in the decade-plus ahead. Now is the time for us all to commit our generation to realize the DoV vision.
David R. Curry is Executive Director of the Center for Vaccine Ethics and Policy, a joint program of the Penn Center for Bioethics, the Wistar Institute Vaccine Center, the Vaccine Education Center of the Children’s Hospital of Philadelphia.
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.