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This blog was originally posted on March 6, 2018 in Pajhwok Afghan News.

By Lois Privor-Dumm and Dr. Ghulam Dastagir Nazary

Afghanistan is a country under siege, but one threat doesn’t make the news. The toll is felt among the most vulnerable in an already fragile country. Every year, nearly 5,000 children under five die of rotavirus, a fast-moving and severe form of diarrhea. Afghanistan’s rotavirus death rate is among the highest of any country in Asia.  

Fortunately, Afghanistan is among the frontrunners in Asia to introduce rotavirus vaccine for children to prevent this life-threatening disease. The vaccine, which will be available for free in health facilities throughout the country, is the 10th vaccine to be introduced in the national immunization schedule.

Click here to read more.

Afghanistan Immunization Poster UNICEF

Image courtesy of UNICEF

Cervical Cancer Campaign in Vietnam

Photo above: School girls at an HPV vaccination campaign event in Vietnam.
© 2007 Amynah Janmohamed, Courtesy of Photoshare

Despite effective vaccines, screening, and treatment, cervical cancer still kills hundreds of thousands of women, most outside rich countries. Experts call for scaling up proven solutions to prevent this.

Cervical health scares have reached mainstream awareness in pop culture, between Abbie in the film 20th Century Women, Hannah on HBO’s Girls, and Sharon on Channel 4’s Catastrophe.  

While a terrifying specter to these LA, New York, and London women, cervical cancer isn’t among the top 5 cancer killers in highly developed regions. Eight of every 10 cervical cancers occur in low- and middle-income countries. While this cancer is preventable, over 230,000 women globally die every year–most in low-resource countries, like those in Sub-Saharan Africa.

As the world observes World Cancer Day this year, we issue a challenge to all to remain focused on the continuing challenges preventing us from reaching more girls and women with effective primary and secondary cervical cancer prevention services in low- and middle-income countries. It’s time to take action, to take the tools we have and start building evidence-based programs, with communities, for the future.

cervical cancer

Photo: In Mozambique, nurse Celeste Machava and Cristina José discuss cervical cancer symptoms, screening and treatment during a medical consultation (Photo: Fernando Fidélis /Jhpiego).

Primary Prevention with HPV Vaccines

More than 3 out of 4 women globally will contract HPV, the primary cause of cervical cancer, within their lifetime. Three currently available HPV vaccines have close to 100% efficacy1 at preventing persistent infection and pre-cancerous disease caused by the two HPV types that cause 70% of the world’s cervical cancer, all with minimal and mild adverse reactions. The newest vaccine directly protects against 5 additional HPV types, which together account for another 20% of the world’s cervical cancer.

Vaccines are hailed as the best buy in public health: Compared to the considerable cost of treatment and lost productivity from cervical cancer, vaccinating girls against cervical cancer is usually a cost-effective investment2 for countries, particularly in a low-resource setting.


Photo: Education and counseling is a key component in cervical cancer screening. A health care provider in Abidjan, Cote d’Ivoire is using a job aid to explain the screening results.  (Photo courtesy of Ricky Lu)

What’s next in the vaccine landscape?

1. Taking steps to reduce vaccine price and ensure reliable supply. Currently licensed HPV vaccines are expensive compared to older, routine immunizations. A global HPV vaccine supply shortage over the past few years has also affected access for girls in the highest-burden, most price-sensitive countries.

But new vaccines must show equivalence against already-approved vaccines. To do this, companies need lab tests that allow direct comparison of molecular and immunology markers—tests that don’t yet exist. Looking to the future, the U.S. National Cancer Institute has launched a new initiative3 to develop and evaluate this type of lab test, opening the way for the development of new, potentially lower-cost HPV vaccines.

2. Reducing the number of doses. The World Health Organization (WHO) recommends two doses of HPV vaccine for girls aged 9-14, at least 6 months apart. Young people who are 15 years old and older, as well as people with a compromised immune system should get a third dose. Scientists are studying whether or not a single dose, or at least a much lengthier between-dose interval, might be as good as two doses. If the results are promising, this study could remove the logistical challenge of tracking down each girl to administer an additional dose for full coverage and reduce costs.


Informational poster

Photo: Poster announcing a screening campaign in San Juan De Lurigancho, in Peru. (Photo courtesy of Ricky Lu) 

Secondary Prevention: finding and treating pre-cancers

Tools for early detection and treatment of the precursors to cervical cancer build upon a solid basis of proven interventions. Yet to effectively prevent cervical cancer in low-resource settings, there are remaining challenges:

3. Scaling up the use of vinegar to identify abnormal cells. Cytology screening, wherein lab workers inspect cells from the cervix under the microscope for abnormalities, is relatively costly and requires access to a functioning and staffed laboratory system. Visual Inspection using Acetic Acid (VIA) technique, which has been used for over a decade, is a safe, effective alternative for onsite screening where there is no lab equipment or personnel. Most well trained health workers can perform this task—task shifting is an important cost savings technique. However, VIA requires robust quality assurance and a large pool of trained providers if it is to be delivered to women at scale. 


3. Reducing test prices. HPV DNA tests are quite accurate at flagging persistent and chronic infection with cancer causing human papilloma virus. Also, while cytology and VIA require pelvic examinations, women can collect HPV DNA tests at home or at a health facility. Facilities can process many tests together to maximize cost effectiveness. However, the tests require an initial start-up investment as well as continuing financing to purchase test kits and supplies. 

4. Expanding options for freezing therapies. Cryotherapy currently uses compressed nitrous oxide or carbon dioxide to freeze abnormal cells off the cervix so normal ones can grow back. Providers who aren’t physicians can be trained to provide the therapy, but machines require reliable gas supply as well as equipment maintenance and transport. Clinical trials are underway to develop new and more practical delivery approaches. Two promising developments are the gasless Cryopen and the dry-ice based CryoPop4. Both destroy the pre-cancerous lesion by freezing the offensive tissue.  

5. Heating to destroy precancerous cells. Thermal Coagulation, in which heat at 100-120 degree Celsius is applied to the cervix to destroy precancer lesions, is being clinically and programmatically evaluated to determine its effectiveness and safety by the International Agency for Research in Cancer.

cryotherapy orientation

Photo: An orientation on cryotherapy through clinical simulation for nurses and clinical officers in Nairobi, Kenya (Photo courtesy of Ricky Lu)

What lies ahead?

We have powerful tools: safe, effective vaccines, and many tested strategies to prevent cervical cancer. We welcome your ideas about additional opportunities to leap across barriers we’ve noted, as well as many others, and address this pervasive threat to women the world over.

Mary Carol Jennings, MD, MPH, is a public health physician and a scientist at the International Vaccine Access Center, in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health. She serves as the IVAC HPV Technical Lead, and her research and work focus on innovative ways to ensure equitable vaccine delivery. Reach her at

Ricky Lu, MD, MPH is a public health physician and directs the FP/RH and Cervical Cancer Prevention unit at Jhpiego, an affiliate of the Johns Hopkins University and an implementing agency operating in over 40 countries globally.  He leads the Jhpiego cervical cancer prevention effort partnering with MOHs to strengthen their prevention and control program. Reach him at


1Chow EP, Danielewski JA, Fehler G, Tabrizi SN, Law MG, Bradshaw CS, Garland SM, Chen MY, Fairley CK. Human papillomavirus in young women with chlamydia trachomatis infection 7 years after the australian human papillomavirus vaccination programme: A cross-sectional study. The Lancet Infectious Diseases 2015;15(11):1314-23.

2Brisson M, Jit M, Boily M, Laprise J, Martin D, Drolet M, Alary M, Benard E. Modelling estimates of the incremental effectiveness & cost-effectiveness of HPV vaccination: Executive summary. ; 2016. Available from:

3Cole M. New HPV Serology Laboratory Aims to Standardize Assays and Contribute to Vaccine Implementation and Access [Internet]National Cancer Institute: Frederick National Laboratory for Cancer Research; accessed Jan 21 2018, Available from:

4Varady, M. et al. (2015) CryoPop: Merging design with demand to build a low-cost cervical cancer prevention toolAnnals of Global Health , Volume 81 , Issue 1 , 201. Retrieved from:

This article was originally posted on the Impatient Optimists Blog on January 9, 2018.

45 million children have access today, millions more expected to gain access to vaccine in 2018

When I started my career in the 1970’s, I saw children die every day from severe diarrheal disease. Today, diarrhea is still responsible for half a million deaths in children under 5 worldwide. That is far too many—acute diarrhea is both preventable and treatable.

Many of these deaths occur because our prevention tools have yet to reach the world’s vulnerable children. The leading cause of severe diarrhea globally is rotavirus, which countries have taken steps to address. After one of the fastest global rollout campaigns in history, 93 countries (home to 1/3 of the world’s children) now include rotavirus vaccines in their national immunization programs.

Introducing vaccines will not completely solve the problem—vaccine coverage must be improved, as must coverage of oral rehydration therapy and zinc supplementation to further reduce the number of deaths and serious illness. Yet, the progress has been remarkable.

Here are 5 reasons we have made it here today:

1. Political leadership in South Asia has been critical

In 2016, India was the first South Asian country to introduce rotavirus vaccines into its public program, using a phased approach. A year later, Pakistan followed suit. Once these programs scale up, the vaccine should reach over 30 million children annually.  Keeping with this trend, Afghanistan, Bangladesh, and Nepal plan to use Gavi support to introduce the vaccine in 2018 and 2019.  

Pakistan Vaccine Poster

Vaccinator in South Asia

2. African countries were early adopters and have been at the vanguard 

African countries have been the vanguard of rotavirus vaccine introduction, which began when South Africa introduced in 2009. Since then, the WHO Regional Office for Africa has found that rotavirus-confirmed diarrhea hospitalizations in children under five has declined by one-third. 

The progress does not end there. 33 African countries have rotavirus in their national vaccine schedule, many having received support from Gavi, the Vaccine Alliance. Several large countries here plan to introduce rotavirus vaccines in the next few years. These include Nigeria and the Democratic Republic of Congo, where more than 40,000 children died from rotavirus in 2013. 

3. Manufacturing developments are expanding choice, potentially reducing prices 

Many new vaccines are in development or recently licensed in Asian countries. Notably, two newly licensed Indian vaccines are soon expected to be prequalified by the WHO: ROTAVAC, from Bharat Biotech, and ROTASIIL, from Serum Institute of India. Once prequalified, UNICEF can supply these new vaccines in Gavi-eligible countries. Expanding choices between vaccine products can drive down market prices and avoid supply constraints. You can read more about this here.

4. Scientists and communicators on the frontlines have enabled progress

Scientific leadership can drive political will to improve child health. Take Bangladesh as an example, which once struggled with extremely high child mortality. Widespread use and excellent coverage of new vaccines helped reverse this trend. Pivotal figures, including my colleagues Shams El Arifeen, K. Zaman, and Samir Saha, published evidence spanning three decades about the toll of rotavirus and diarrheal disease on Bangladeshi children and families.

Still, challenges exist. Bangladesh must double the country’s cold chain capacity and cope with an influx of over 600,000 Rohingya refugees. Beyond this, we recently found that thousands of children were turned away from a pediatric hospital due to a lack of beds. If these children had been vaccinated against rotavirus, the hospital may not have been overburdened in this way.

5. Middle-income countries face unique challenges 

For middle income countries like Thailand and the Philippines, it remains to be seen whether expanding supply choices will impact pricing and decision-making. The Philippines began a phased introduction in 2012 but has yet to scale up use. In Thailand, a pilot introduction showed that rotavirus vaccine would be efficacious and cost-effective. However, the scientists calculated based on current pricing that to purchase the vaccine for all children would be equal to 45% of the current budget for Thailand’s entire immunization program. Fortunately, the expansion in supply may change this calculus.

What Now?

Even with all this progress, can we feel hopeful that still 2 out of 3 children in the world don’t have access to vaccines that developed nations take for granted?

 I am an optimist and I have seen seemingly impossible journeys come to fruition. Achieving vaccine equity is a marathon, not a sprint, and the global community should applaud the many countries taking this important step toward ensuring a healthy start for all children.

More Resources

View-Hub Image of Rotavirus Coverage

This image is courtesy of View-Hub


Nina Martin, PhD and Mary Carol Jennings, MD


Listen to the full episode: Public Health United Episode 57: Mary Carol Jennings on Accelerating Vaccine Access


This week, PHU host Dr. Nina Martin speaks with Mary Carol Jennings, MD, Assistant Scientist at IVAC. Listen to the podcast here, or read below to learn more.

Who is Dr. Mary Carol Jennings?

Dr. Jennings is a physician-scientist who has seamlessly paired her training in obstetrics and gynecology, and preventive medicine, with her desire to affect positive change in the global health field. Before she became a physician, she worked as a community organizer internationally and here in the US. At IVAC, she directs the RAVIN project, a vaccine access accelerator program, and is the Center’s lead on developing new projects for the primary prevention of cervical cancer – i.e. through HPV vaccines.

What does it mean to accelerate vaccine access?

Dr. Jennings works to “understand the communities that are not getting access to really powerful prevention tools: vaccines.”

In this episode, Dr. Jennings speaks about her work on the Rotavirus Accelerated Vaccine Introduction Network (RAVIN) project, which aims to shrink the gaps in vaccine access between richer and poorer countries. RAVIN has a specific focus on rotavirus vaccine, which prevents a common yet severe infection that hospitalizes millions of children and kills over 200,000 every year.

Dr. Jennings also speaks about the new projects she is leading at IVAC. Cervical cancer is one of the most common cancers in the world, yet it is vaccine preventable. Dr. Jennings explains how she hopes to expand vaccine access to hard-to-reach communities, such as out-of-school girls in selected communities in India, who are not typically targeted populations to receive these vaccines.

"Where are the communities that lack access to vaccines? Why are they not experiencing equal levels of access and what can be done about it?” Learn more in the Public Health United podcast interview with Dr. Jennings.

What is Public Health United?

Public Health United, Inc. (PHU) is a non-profit organization that improves science communication through podcasts, outreach, and public engagement training for scientists. Dr. Nina Martin is PHU’s Chief Executive and host of their weekly podcast, with each episode featuring a different public health science expert with stories and insights on science communication.  At IVAC, Nina does research on adult vaccines on the Policy and Advocacy Communications Team.

Click here to listen or download the episode


Related Episode Links:

·       Dr. Mary Carol Jennings Bloomberg Faculty Page

·       Learn more about HPV at Gavi

·       Learn about Alliance for a Healthier World, which supports Dr. Jennings’s cervical cancer awareness project

·       Connect with Dr. Jennings on LinkedIn

·       Follow Dr. Jennings on Twitter

Nina Kate Swati selfie

Nina Martin, Kate O'Brien, and Swati Sudarsan, IVAC


Listen to the full episode: Public Health United Episode 52: Kate O’Brien on Vaccines and Social Justice


What is PHU?

Public Health United, Inc. (PHU) is a non-profit organization that improves science communication through podcasts, outreach, and public engagement training for scientists. Dr. Nina Martin is PHU’s Chief Executive and host of their weekly podcast, with each episode featuring a different public health science expert with stories and insights on science communication.  At IVAC, Nina does research on adult vaccines on the Policy and Advocacy Communications Team.

PHU recently featured Executive Director of IVAC, Kate O’Brien. The podcast was co-hosted by Swati Sudarsan, who works on pneumonia advocacy and global coordination on IVAC’s Policy and Advocacy Communications Team.

Who is Dr. Kate O’Brien?

Kate is a sitting member of the Strategic Advisory Group of Experts (SAGE), which advises the World Health Organization on global vaccine policy, and serves on the Gavi Board representing the Technical and Research constituency. She is a senior advisor at the Center for American Indian Health, and of course, a beloved professor in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health.

Can't listen, but want the info?

During this episode, Kate tells us a little about who she is and why we should care about vaccines. A pediatrician by training, she explains that her passion for health equity was fostered during her time in Haiti, where she saw first-hand the consequences of vaccine-preventable disease on children. Here she developed “a deep desire to contribute to the vaccine world.” Because of this experience, Kate believes that vaccines are fundamentally a social justice issue. The current reality that a poorer person is less likely to be vaccinated than someone from a higher income setting is what she calls “a moral failing” of our society.

Part of the reason this happens is because there needs to be greater financing for vaccines. Kate is working to advance scientific discussions by helping quantify the “full public health value of vaccines.” For example, vaccines not only prevent disease in an immunized child, but they can protect the people around them, can help families avert the costs of hospitalization from disease, and can even help mitigate an emerging crisis – antibiotic resistance.  Kate is also working to make vaccines more accessible to families in novel ways. For example, new evidence has demonstrated that fewer doses of pneumococcal conjugate vaccine (PCV) may be effective in areas where pneumonia transmission is virtually eliminated and thus be able to save government’s billions of dollars, an important benefit to global vaccine policy and implementation.

Kate’s passion for vaccines extends beyond the office and to her family dining table. This holiday season, take Kate’s advice and talk to your family about their vaccination status. For more on Kate’s take, click here to listen or download the episode.


Related Episode Links:

·       Full list of PHU podcasts

·       Join the online discussion on Twitter with IVAC and PHU.

·       Kate’s profile at JHSPH

·       SAGE at WHO (expert panel on immunization)

·       Kate’s World Health Organization (WHO) Profile

·       Kate is quoted in this November 2017 National Geographic feature, “Here’s Why Vaccines Are So Crucial”

·       Journal article in Vaccine (Oct 2017): ‘Estimating full public health value of vaccines”

·       Gavi: The Vaccine Alliance



Mar 2018