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Johns Hopkins Bloomberg School of Public Health



This post is part of the #ProtectingKids story roundup. Read all the stories here.

There is a popular saying that you cannot manage what you cannot measure. This is so true for the global effort to close the immunization gap. We need to localize and measure the gap before we can close it. Having good immunization data to evaluate how well we are reaching all children is a critical ingredient for success.

I was poignantly reminded of this fact a few weeks ago when I visited Damangaza community, an urban slum in Nigeria’s Federal Capital Territory, where one of our Women Advocates for Vaccine Access (WAVA) member works. A temporary settlement, Damangaza is made of mud huts, open sewers, zero infrastructure, friendly adults and playful children. This generous community hosts more residents than it can comfortably accommodate, even welcoming internally displaced families fleeing from Boko Haram. A mere 20 minutes drive from the heart of Abuja, the contrast in wealth and access between the community and the nearby Abuja city center couldn’t be any starker.

When WAVA member, Vaccine Network, began working in Damangaza a few years ago, majority of the children had never been vaccinated. The year before, an outbreak of measles swept through the community killing many children in its wake. Although by no means hard to reach, a community like this is one of many settings where children easily fall through the cracks and are missed by immunization services.

Little wonder current data shows that one in five African children is under-vaccinated. If we are to reach that fifth child, we need accurate and timely data to tell us who that child is, where they live and why they are missed. This is a big challenge in Nigeria where the two main sources of immunization data (survey and administrative) do not speak to each other.

Survey data is obtained by interviewing a representative sample of households in the communities about their child’s immunization status. The main ones are the National Demographic Health Survey (NDHS) or the National Immunization Coverage Survey (NICS) conducted every 4 to 5 years. Survey data is richer in details and considered the gold standard. Administrative data on the other hand is based on clinic and health facility records of children who are vaccinated in fixed or outreach posts; it is collated monthly. It is therefore more available to support program management.

Unfortunately, there is usually wide disagreement between the administrative and survey coverage estimates, with the administrative always higher than the survey for comparable years. For example, national coverage with the third dose of the pentavalent vaccine in the 2013 NDHS survey was 38% but 58% by administrative data.  Put another way, survey says we reached nearly 4 in 10 kids while administrative says we reached nearly 6 in 10 kids. Which data is accurate?

Diving deeper in the NDHS 2013 raises concerns about retention in care and equity of coverage. For example, while 51% of Nigerian children get their first dose of pentavalent, only 38% end up receiving all three recommended doses, reflecting an absolute drop out rate of 25%. Furthermore, only a quarter of one-year olds received all required vaccines, while as many as 1 in 5 received no vaccines at all.

Looking the beyond the national average reveals staggering disparities by geography, residence, mother’s education and wealth quintiles. According to the NDHS, a child in the north western state of Sokoto is 32 times less likely to be vaccinated than his peer in the south eastern state of Imo. A child living in a rural area is 2.5 times less likely to be vaccinated than her mate in the city. If a child is born of a mother with no education, that child is 7 times less likely to be vaccinated than another child whose mother has secondary school education or more. Children from the poorest fifth of the wealth ladder are 11 times less likely to be vaccinated than their peers from the richest fifth.

Sobering statistics indeed. As I cradled adorable twins Hassan and Husiana in my arms during my visit to Damangaza, I knew the odds were stacked against them in terms of access to vaccination. Their mother had no education, she was in the lowest rung of the wealth ladder and they live in an urban slum. But then again, it struck me that their disadvantage can be overcome if we are intentional about finding and vaccinating children like them wherever they may be. But we will need good and timely data to do that. If administrative data over estimates coverage, we will have a false sense of accomplishment and still miss many children. If survey data is accurate but comes only twice in a decade, it is too infrequent to help us manage the program. We must find an alternative.

Chizoba Wonodi
Dr. Chizoba Wonodi is the Nigeria Country Program Lead at IVAC.

As the global community works on ways to improve immunization data, I see a third way. This is to empower communities to generate and use their own data to track births and children’s immunization status. Through IVAC’s work on accountability for routine immunization in Nigeria, I have seen that it is possible use community structures like religious and traditional leaders or Ward and Village Development Committees to count how many children are born in the community every month. If health workers have an accurate number of births in their catchment area, the true target population, it is easy for them to measure how well they are doing with vaccinating kids.

Community structures can also be used to track dropouts or left-outs, tracing them right down to the compound and household where the children live. Such real time information will not only help the health worker do their job better, it will also give community leaders a sense of ownership of the immunization program. I look forward to the day when a village chief can tell his community’s target population and vaccination coverage; that day will bring us many steps closer to bridging the immunization gap. Data is not just for experts and nerds; it is for all of us.

Dr. Chizoba Wonodi is the Nigeria Country Program Lead at IVAC.

This post is part of the #ProtectingKids story roundup. Read all the stories here.

Lakki Marwat, Khyber Pakhtunkhwa, Pakistan

From birth to 15 months, 6 visits to the Immunization Center your child will be protected from 9 vaccine preventable diseases. Repeat after me and memorize these numbers as you did your tables in school.

As some 20 heads nod in agreement, I realized many women and girls sitting in this veranda may never have gone to school. This was an awareness session with community women of Lakki Marwat. The district in Pakistan's northwestern province of Khyber Pakhtunkhwa has a dismally low immunization coverage.

Although it was an all women session, many women had not taken off their burqa (the one which are more popularly known as the shuttlecock burqa which covers them head to toe with just a net near the face to let them see and perhaps breathe a little) for fear that a male glance may fall on them.

Although, I had heard a lot about Lakki Marwat, this was my first visit ever to the place. Khyber Pakhtunkhwa is a conservative province, but Lakki Marwat is by far the most conservative of all the districts.

I was conducting an awareness session with the community women in Lakki. I wanted to speak to young mothers and even mothers in law and tell them the value of vaccination, how it can save their children from diseases and, best of all, it cost them nothing for that. I was also very curious to find out, despite all the benefits, what prevented them from getting their children vaccinated and what could be done to improve the coverage.

I was amazed at the level of excitement and interest. They were all ears, listening in rapt silence. Giving me utmost respect and importance, they raised their hands and patiently awaited their turn if they had a query.

Pakistan is a large country with high child mortality and low immunization coverage. More than 1,000 children under five die each day. Just over half of Pakistani children are fully vaccinated against all nine diseases included in the EPI, with tremendous variation between provinces (Source: 2012-2013 PDHS). It is an important country in the immunization world, and among the last two still fighting the polio virus.

There are severe provincial disparities and marked variations in immunization coverage in provinces and districts, and by gender. A survey conducted to analyze the causes and barriers of routine immunization in three districts of Khyber Pakhtunkhwa (which included Lakki Marwat) by Japan International Cooperation Agency (JICA) late last year indicated an unfortunate 78 percent illiteracy rate amongst women in Lakki district. Knowledge of mothers that children require immunization six times was only 12 percent.

In a comparison on gender differences of children (12-23 months) who had missed routine immunization, that of girls in that area turned out to be 64 percent as compared to boys.

There are several demand and supply side challenges for this low and fragmented progress. Public awareness of benefits is low and local authorities don’t view immunization as a priority. The gap in immunization knowledge among the community impedes them from actively seeking immunization services.

But despite systemic weaknesses, the province is taking impressive steps to not only improve but improve equitable immunization coverage. Lakki Marwat will be amongst the three priority districts in which the provincial government will be working on social mobilization in 2016.

One thing was evident – this was not a place frequented by visitors from other towns, let alone women. I recalled when, during our discussion, the Khyber Pakhtunkhwa EPI Program Manager had, in a sort of challenging cum daring tone, suggested Lakki for the advocacy session with community, if I was really serious in doing a meaningful session. However, while confirming the date and venue, the District EPI Coordinator of Lakki had clearly said I should return home by evening alluding to the place not being safe for women to stay the night.

Knowingly leaving this last piece of information from any conversation I had with my family on my impending visit to Lakki, I did, however, return the same night travelling a good 13 hours on the road. In retrospect, it was one journey I found to be far more satisfying than many others I have taken in my quest to spread the knowledge about the value of vaccinating children against childhood diseases.

Huma Khawar is an IVAC consultant who works on immunization advocacy with stakeholders on the ground in Pakistan.

Mosquitos breed in standing water

By Dagna Constenla, Gatien de Broucker and Jorge Martin del Campo

This article was originally published in the Dengue Vaccine Initiative newsletter on March 7, 2016, available publicly here.  It is cross-posted here with permission. IVAC is a member of the Dengue Vaccine Initiative (DVI).

A public health emergency of international concern

It’s summer in Brazil now and the sweltering heat of the Northeast Atlantic coast of the country drives many people outdoors where they come into contact with the Zika virus. In Recife, the capital of the state of Pernambuco where a third of the 4,000 reported cases of microcephaly in Brazil have been reported since early 2015, many people cannot afford to buy insect repellent in their local pharmacies. Most families in this part of the country live in impoverished areas with no running water and near open drums that serve as breeding grounds for the mosquito vector. Air conditioning and window screens that could help keep the mosquitoes out are prohibitively expensive.

Today, 24 of 26 states in Brazil are grappling with the rapid spread of the virus. This outbreak, driven by the global trends of population growth, urbanization, globalization expansion of mosquito vectors and the effects of El Niño, shows no signs of abating this year. Every day up to five new microcephaly cases are diagnosed, creating chaos and a break down in primary health care as hospitals and clinics become overburdened with mothers whose babies are waiting to be seen by pediatric neurologists and other specialists.

While the link between Zika virus infection and microcephaly in babies is still under investigation, the sudden exponential rise of cases, following closely the rise of Zika cases is unnerving. This situation has forced the World Health Organization to declare the epidemic of microcephaly cases in regions affected by Zika virus a matter of public health emergency of international concern. If the link between Zika and microcephaly is proven biologically, and evidence are cumulating in support of this relationship, the impact of the mounting epidemic will be far-reaching for Brazil and countries and territories with active Zika virus transmission.

People in Brazil are concerned about the uncertainty and risk of this outbreak and the lack of information regarding the virus. The concern is even greater among pregnant women who don’t understand the long-term implications of the Zika virus on their baby’s life: will their baby’s head fully grow? Will their baby be able to talk and walk? Will they be able to hear? Will they be able to attend school?

The prognosis for children born with microcephaly varies, according to the National Institute of Neurological Disorders, depending on the severity of the symptoms, ranging from impaired cognitive development to delayed motor functions and speech. Brazil’s Health Minister and health care officials in Colombia, El Salvador and the remaining 21 countries and territories of the Americas with Zika outbreaks have advised women of reproductive age to delay pregnancy.

While the Zika virus is new to Brazil and other countries of the region, Aedes Aegypti, the mosquito that spreads the disease, is well known for causing other emerging infectious diseases like dengue, Chikungunya and yellow fever.

Macroeconomic impact of the Zika virus

Beyond the silent suffering among those directly affected by the Zika virus, state officials have raised concerns about the negative impact that the Zika outbreak will have on the economy of Brazil and beyond. One concern is the potential negative impact of the Zika virus on the tourism industry last month (February), just when the Carnival season begins, and during the Olympic Games scheduled for August 2016 in Rio de Janeiro. Though currently there are no travel restrictions imposed by the World Health Organization (WHO), there have been anecdotal reports about international airlines already cancelling or rescheduling flights for passengers that are traveling to the region that are pregnant or may become pregnant. Moreover, evidence is emerging on the impact that Aedes Aegypti diseases have on tourism revenues. In their 2009 report, Mavalankar and colleagues quantified the impact of Chikungunya and dengue on tourism revenues of three Asian economies: the state of Gujarat in India, Malaysia and Thailand. They reported a substantial loss of tourism revenues: an estimated 4% decline, which represents at least US$ 8 million for Gujarat, US$ 65 million for Malaysia and US$ 363 million for Thailand.  

Added to the potential significant losses associated with tourism, the possible decline on foreign direct investment due to the Zika outbreak is a major concern. During the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak, mainland China reported a decline of US$ 2.7 billion and Hong Kong foreign direct investment inflows fell 62% in one quarter. When the outbreak ended, this decline in foreign direct investment inflows was reversed.

Investments in outbreak control and surveillance infrastructure may also be impacted by the recent Zika outbreak. Recently, Brazilian authorities invested considerable resources to prevent the growth and spread of dengue. Funding for dengue outbreak prevention registered an increase of 32% over the last four years, from BRL $ 947.7 million in 2012 to $ 1.25 billion, in 2015. This funding was invested in supporting surveillance and preventive measures as well as in studying dengue. These investments are expected to increase with the rapid spread of the Zika virus. As the government of Brazil continues to make investments on preventive and control measures of Aedes Aegypti diseases, the government will continue to make debt repayments in the absence of significant financial inflows to finance outbreak control and surveillance infrastructure.

The loss of productivity due to the Zika outbreak is an even greater concern. Children with microcephaly may not have the ability to achieve their full cognitive potential because they are generally born with impaired cognitive and physical development. Moreover, children who are physically and cognitively disadvantaged are less likely to attend school, resulting in lower educational achievement.

At a macro level, the Zika outbreak could have other long-term repercussions. The government in Brazil and other countries in the region are already advising women of reproductive age to postpone pregnancies anywhere from six months to two years. If women in the region observe these warnings for a significant period of time, there may be a decrease in pregnancies that will ultimately result in a decrease in population growth. This could negatively impact the continued productivity associated with the sizable workforce in Brazil and the region as a whole.

What can we expect?

In terms of opportunities in containing the spread of the virus, recent advances in dengue research have resulted in development of new tools that show promise for use in prevention and control of other Aedes Aegypti diseases. These include vaccines*, antiviral drugs, therapeutic antibodies, biomarkers for severe disease, and mosquito-control methods that are biological, genetic and insecticidal in nature. Many of these new tools will not become available for use for another three to five years. The full potential of these tools, in terms of decreased transmission and prevention of major epidemics of dengue and other Aedes transmitted viruses, will be realized if used together instead of independently.

There are several challenges that Brazil and other Zika-affected countries in the Americas face to contain the spread of the virus. Currently, an overall strategy is lacking to effectively use these new tools and to educate the affected communities. Funding for research in this area and operational program implementation are fragmented and often uncoordinated. However, Brazil’s institutional capacity to manage outbreaks shows promise. The Oswaldo Cruz Foundation is one of many credible, government-funded institutions working to characterize Aedes transmitted viruses, like Zika, and its epidemiology. Moreover, a strong community of health networks across all states in Brazil is helping to promote positive behavioral changes that can temper the spread of Zika at the community and household levels so, next year, when those sweltering in the heat of the Northeastern Atlantic coast of Recife come into contact with Zika, they may be at a lower risk of contracting the virus.

* Denvaxia® has recently become available for the prevention of dengue. There are many other dengue vaccine candidates in the pipeline. No vaccines are currently available to target the Zika virus.

This article was originally published on the Dengue Vaccine Initiative website and is cross-posted here with permission. IVAC is a member of the Dengue Vaccine Initiative (DVI). 

On December 9 2015, Mexico approved Sanofi Pasteur’s dengue vaccine marking the first time a dengue vaccine has been licensed for use in a country. Called Dengvaxia® and developed by the French pharmaceutical company, Sanofi Pasteur, the vaccine was approved for people aged 9 to 45 years in areas that are highly endemic, with a dengue seroprevalence of more than 60 percent.

The Dengue Vaccine Initiative (DVI) views Mexico’s licensure of Dengvaxia® as an important milestone in the fight against dengue. Recent studies have demonstrated that in children and adolescents aged 9 years and above, Dengvaxia® reduces dengue cases overall by approximately 65 percent; dengue cases requiring hospitalization by 81 percent; and severe dengue cases by 93 percent. The vaccine’s efficacy was most apparent in individuals with evidence of prior dengue virus exposure. In children below the age of 9 years and in those with no evidence of prior dengue, the vaccine’s efficacy was substantially lower. There was also an increased risk of cases requiring hospitalization during the third year after vaccine initiation in children under 9.

These results suggest that Dengvaxia® may have significant public health impact in reducing dengue disease burden for people 9 years of age and older, especially in areas with existing high infection rates of dengue. Questions remain regarding Dengvaxia®, including duration of protection, price, and impact on overall dengue virus transmission given that the youngest age groups will not be vaccinated. These and other issues will have to be closely followed in order to ascertain the ultimate impact of this vaccine.

Dengue, also known as “breakbone fever,” is caused by a virus transmitted by Aedes mosquitoes, the same mosquitoes that can transmit chikungunya and Zika virus. Dengue virus causes approximately 400 million infections globally each year. In the Americas alone, dengue’s economic burden has been estimated to cost $2.1 billion dollars a year.

DVI believes that this first vaccine licensure in a dengue-endemic country may pave the way for other countries considering new technologies to fight dengue, but stresses that the decision to introduce a dengue vaccine should follow scientific evidence. Following registration, ministries of health will still face important decisions about whether and how to introduce the vaccine into national programs. These decisions may vary according to the specific demographic characteristics, dengue epidemiology and the capacity of public health systems of each country. Therefore, DVI continues to strongly support increasing efforts to improve endemic countries’ access to the evidence needed to inform vaccine introduction decisions.

DVI also welcomes the decision by Mexico as an opportunity to increase our understanding of the questions raised above, as well as the effectiveness of the vaccine in field conditions. DVI recognizes the importance of effective integration of dengue prevention and control strategies, notably vaccination and vector-control approaches, to comprehensively reduce dengue. DVI also encourages the global health community to facilitate and support mechanisms for regional knowledge transfers and information sharing among endemic countries to collectively fight dengue and other vector-borne diseases that are also on the rise. We hope this development spurs other vaccine candidates currently in clinical development to continue to progress in the pipeline.

About the Dengue Vaccine Initiative
The Dengue Vaccine Initiative is an international consortium of the International Vaccine Institute, the World Health Organization Initiative for Vaccine Research, the International Vaccine Access Center at the Johns Hopkins University Bloomberg School of Public Health and the Sabin Vaccine Institute that specializes in research, health economics, policy and advocacy to equip countries with objective information and scientific evidence to fight dengue fever. The Initiative is supported by the Bill & Melinda Gates Foundation.

By Rose Weeks

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


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.


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 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.