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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.

By Huma Khawar, freelance journalist and consultant for Vaccine Implementation Technical Advisory Consortium (VITAC).

This article was originally published on the VaccinesWork blog and is cross-posted here with permission.

Girl with vaccine card

A little girl with her vaccination card. Photo: Gavi/Doune Porter

Doctors from across Pakistan gathered in Islamabad last Thursday to fight a disease that’s threatening children across the country. This time it wasn’t polio they were working against, but pneumonia, which kills as many as 71,000 children every year in Pakistan.

The event, held to mark World Pneumonia Day, aimed to empower key influencers to better advocate to stop pneumonia and discuss challenges to its prevention. It took place at the Children’s Hospital, Pakistan Institute of Medical Sciences (PIMS), which itself sees many cases of the disease with a daily turnover of over 500 children in its outpatient department from in and around Islamabad.

WPD Seminar Event

The entrance to the seminar. Photo: Huma Khawar.

The pneumococcal vaccine was rolled out in Pakistan in 2012 as part of the routine immunization schedule, when it had already helped children in many other countries avoid pneumonia. It is also proving effective in Pakistan, as Dr. Asad Ali, from Aga Khan University Karachi, demonstrated by sharing preliminary findings from the vaccine impact assessment in Sindh. He explained that even one dose of pneumococcal vaccine is highly effective against the main germs that cause pneumonia (pneumococcus and Hib).

However, pneumonia is still one of the major killers of children under five years old in Pakistan.  A major reason is limited routine immunization coverage – a little more than 50% of children are covered by a basic set of vaccines nationally, and the numbers of children immunized has even been declining in Balochistan. As a result, pneumococcal vaccine faces challenges reaching children across the whole country through this system, and so its population-level effects cannot yet be expected to be significant.

Doctors estimated that this underperformance is fuelled by caregivers’ lack of awareness. Too few parents know that the vaccine is necessary for child health, free-of-cost and available at immunization centers nationally. Yet improving vaccine coverage is crucial, as once infected, access to treatment options for infants remain limited especially in Pakistan’s rural, impoverished regions. Dr. Syed Saqlain Ahmad Gillani, National Immunization Program Manager, concluded the session by voicing support for a public-private health sector partnership to increase routine immunization coverage in the country.

Presentation at Pakistan Event

One presentation from the day. Photo: Huma Khawar.

Facing such a challenge, medical professionals are not the only ones who need to advocate for vaccination against pneumonia. Following the conclusion of the main session, an advocacy session tailored for teachers and headmistresses of public schools was initiated during which they were informed of the need to prevent pneumonia through other proven, low-cost techniques such as immunization, sound hygienic practices and balanced diets for infants and exclusive breast feeding for six months, ensuring good nutrition.

The teachers also shared various risk factors which make children more prone to pneumonia. Poor parental healthcare seeking was one: when children with severe pneumonia often undergo of trial and error at the field levels, before they actually reach the health facility for the right treatment in time.

Exposure to indoor smoke, which in rural Pakistan is an issue for more than 60% of families, is also damaging beyond imagination. There, an average household size is seven, which makes overcrowding (i.e the number of people sharing same room where children sleep) is another important factor contributing to pneumonia.

The teachers agreed that, more than ever before, we know how to protect and prevent children from catching pneumonia, and how to treat those suffering with this illness. They returned home to spread the message. 

By Rachel Bierbrier, a Policy, Advocay and Communications intern working with IVAC. 

International Vaccine Access Center (IVAC) is proud to celebrate the seventh annual World Pneumonia Day on November 12th, 2015.

Despite being preventable and treatable, pneumonia remains the leading killer of children under five years old; responsible for 16% of global under five mortality in 2015. More than half of these deaths occur in only six countries where gaps in access to life saving interventions exist.

Although World Pneumonia Day began seven years ago, IVAC’s commitment to reducing the burden of pneumonia originated much earlier with PneumoADIP; an innovative project that aimed to improve child survival and health by accelerating the evaluation of and access to new, life-saving pneumococcal vaccines for the world's children. Although this project is now complete, it was critical in sparking both the birth of IVAC as an organization and its ongoing commitment to increasing access to pneumonia prevention interventions, with a specific focus on vaccination.

IVAC is thrilled to announce the release of its annual Pneumonia and Diarrhea Progress Report. This year’s theme is Sustainable Progress in the Post-2015 Era. Using the most recent available data, the report documents the progress of the 15 countries with the greatest burden of pneumonia and diarrhea, in implementing high-impact interventions outlined in the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea (GAPPD) relative to GAPPD coverage targets. For the first time, the report includes in depth analysis of the challenges associated with the sustainability of pneumonia and diarrhea interventions in Gavi graduating countries as well as country specific analysis of the challenges and successes in three focus countries - India, Indonesia and Nigeria. The report and other great resources can be found at www.worldpneumoniaday.org.

Other events hosted by IVAC for World Pneumonia Day 2015 are taking place at the Johns Hopkins Bloomberg School of Public Health. An information table with World Pneumonia Day facts and goodies is set up from 12:00pm-1:00pm in front of the school’s Wall of Wonder – to share information with the future leaders of global health. In the evening, the Child Health Society is hosting a talk by IVAC’s own Dr. Laura Hammit. Dr. Hammit’s talk takes place from 5pm - 7pm in the Hampton House Auditorium.

Pneumonia Fighters

In Abuja Nigeria, IVAC has joined forces with the government of Nigeria and the Pediatric Association of Nigeria to host a high-level symposium on pneumonia. During the symposium senate leaders, Senator Olanrewaju Tejuosho and Senator Mao Ohuabunwa, will unveil two creative projects on pneumonia – a World Pneumonia Day Calendar, created from paintings done by teenagers in Abuja, and a Pneumonia Social Media Video Challenge. Using the precision of science and the drama of arts, IVAC is helping to propel the message to #BeatPneumonia.

Student artists whose works were used in the calendar. (Nigeria)

Student artists whose work were featured in the calendar. (Nigeria)

Today, IVAC continues to be active in many pneumonia-related initiatives. In addition to the PERCH project, the PCV Technical Coordination Project and many other innovative projects ongoing at our center, IVAC recently received generous support from the Bill and Melinda Gates Foundation to assume the role as a coordinator for the Global Coalition Against Childhood Pneumonia and Diarrhea. Under this grant, IVAC will work to increase collaboration and communication between members of the Coalition. These activities won’t stop on World Pneumonia Day, they are year round and include the creation and implementation of innovative advocacy tools and efforts.

Pneumonia remains the leading killer of children under the age of five despite being both preventable and treatable. Decreasing the global burden of pneumonia cannot and will not occur without continued advocacy, innovation and collaboration. As a global community, we must continue to work together beyond World Pneumonia Day to ensure that all children have access to sustainable, life saving pneumonia interventions. We have the tools to fight pneumonia; we now need to ensure that these tools are being distributed equitably around the globe.

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.