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.
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.
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.
This image is courtesy of View-Hub
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.
This article was originally published on Global Health Now and is cross-posted here with permission.
By: Dr. Mathuram Santosham
A healthy child in Uttar Pradesh, India, 2010 © Gates Foundation
World Immunization Week provides a moment to reflect on the tremendous progress in reducing one of the world’s leading killers of children—diarrhea.
While oral rehydration solution has significantly reduced diarrheal disease mortality since its adoption in 1978, diarrhea continues to be a major cause of childhood illness and death globally. Rotavirus, the most common cause of severe diarrhea, is responsible for approximately 40% of all diarrhea hospitalizations and hundreds of thousands of deaths in children under 5.
Rotavirus vaccines offer the best protection for children and are an essential part of comprehensive diarrhea control. While the WHO recommends that all countries introduce rotavirus vaccines, only 77 have done so, 34 of which are Gavi-eligible countries where many of the deaths occur. Unfortunately, some of the most vulnerable children and communities do not have access to the vaccine.
In particular, Asia has lagged in introducing rotavirus vaccines, even though it accounts for more than 40% of global rotavirus deaths. To date, no country in the region has introduced the vaccine into its national immunization program.
While dramatic reductions in deaths from childhood diarrheal disease have been achieved in Bangladesh, there are still more than 2.4 million rotavirus cases each year. It causes 2 out of every 3 diarrhea-related hospitalizations among children under 5. There are also serious economic consequences. One episode of rotavirus costs the average Bangladeshi family about USD $80 in direct hospital costs, a significant portion of average monthly income.
In neighboring India, where rotavirus is equally ubiquitous, the disease poses a significant financial burden to families and the country’s economy. Studies have shown that a hospitalization for rotavirus could potentially push a family into poverty or keep them there. Depending on the level of care, the total cost of a rotavirus hospitalization could range anywhere from nearly $32 to more than $135, equal to up to 2 months of income for an average Indian family. Rotavirus also burdens the healthcare system with the high cost of hospitalizations and outpatient visits. One study estimated that hospitalizations and outpatient visits cost India approximately $78 million and $86 million each year, respectively—each more than the estimated $72 million it would cost to fund a rotavirus immunization program.
For fast-growing countries like India and Bangladesh, tackling rotavirus—which cheats children and the nation of productivity, well-being and development—should be a priority. However, the available and effective rotavirus vaccines are not yet available in the national immunization programs of either country.
Many of my scientific colleagues in Bangladesh are making a good case to their leaders for national introduction of rotavirus vaccines. And, I’m inspired by the strides being made in India. Last July, Prime Minister Narendra Modi announced that rotavirus will be included in the Universal Immunization Programme; and just last month, the first India-made rotavirus vaccine, ROTAVAC, was launched. Now is the time to get to the finish line—the cost of delaying access to rotavirus vaccines continues to mount. Together we can close this immunization gap and virtually eliminate rotavirus.
Dr. Mathuram Santosham is the Director of the Center for American Indian Health, Chair of the ROTA Council, and Senior Advisor at the International Vaccine Access Center at Johns Hopkins Bloomberg School of Public Health. Dr. Santosham and his colleagues won an Honorable Mention in GHN's Untold Global Health Stories Contest for their submission of rotavirus in Bangladesh and India. GHN will feature one Honorable Mention story per month from now until the next contest in early 2016.
Mathu Santosham speaking at the Eleventh International Rotavirus Symposium in India.
This post originally appeared on the Impatient Optimists blog and is cross-posted here with permission.
Heading to New Delhi, India recently for the Eleventh International Rotavirus Symposium, I knew that this meeting would be different. Over the past couple of years, notable advancements against rotavirus disease have occurred, including the development of a new indigenously developed vaccine in India, an enormous mass of studies with positive safety and effectiveness results, and many introductions of vaccines into national immunization programs, giving promise that we can beat this leading killer of children.
In the very first moments of my arrival, I learned that my expectations were right.
Never before have more people gathered at this symposium. An astounding 650 experts from 56 countries —more than 16 times as many people who attended our first meeting thirty years ago — came to the conference, themed, “Building on evidence: the case for rotavirus immunization.”
The sheer number and diversity of people are true testaments to the increasing awareness of rotavirus and the essential role of vaccines in reducing the suffering this disease causes.
Pediatricians, epidemiologists, researchers, policy makers, immunization program implementers, government officials and pharmaceutical representatives presented on and heard about a number of important topics. Panels ranged from the Latin American and African experience with vaccines and post-licensure impact and safety of vaccination, to immunity and new insights in strain diversity.
In addition, we discussed the critical policy challenges remaining and advocacy efforts needed to help overcome them. Advocacy among policy-makers, championed by my dear colleague and friend, the late Dr. Ciro de Quadros, along with groundbreaking vaccine development efforts and public-private partnerships are leading to greater prioritization of rotavirus; however, more must be done.
But what also stood out was the excitement of convening this biannual event in India. The new government has made laudable commitments to tackling the burden of rotavirus, and other leading childhood diseases, that will save lives and give all Indian children a chance at being healthy and productive.
Just two months ago, Indian Prime Minister Narendra Modi announced that the Government of India would provide a rotavirus vaccine to all Indian children through the Universal Immunization Program. At the same time, the government has redoubled efforts to improve access to oral rehydration solution (ORS) and other key diarrhea control interventions through its Intensified Diarrhea Control Fortnight. All of these efforts are positive signs for the children of India.
At the symposium, Dr. Harsh Vardhan, India’s Union Minister of State for Health and Family Welfare, spoke about the importance of delivering vaccines to all those in need. Too many children have lost their lives, and too many families are bearing tremendous economic consequences as a result of hospitalizations due to rotavirus. In India, rotavirus is estimated to cause more than 78,000 deaths, 800,000 hospitalizations and three million outpatient visits each year.
However, even with this momentum, we must not become complacent in addressing rotavirus disease, the leading cause of severe and fatal diarrhea in children under five years of age worldwide, killing between a quarter and a half million children each year. While children everywhere are at risk of infection, the majority of deaths occur in South Asia and Sub-Saharan Africa, where children do not have good access to care.
Yet, despite the World Health Organization’s (WHO) recommendation for all countries to introduce rotavirus vaccines in their national immunization programs, only 35 percent of countries worldwide (69) have done so. The most disappointing statistic for me is that only one country in Asia — The Philippines — has introduced the vaccine nationally.
Additionally, while vaccination is the best way to protect children from rotavirus, a comprehensive approach will best protect child health and boost immunity. Vaccination should be part of a broad strategy that includes improved water, sanitation and hygiene; good nutrition; breastfeeding; ORS; and zinc supplementation.
I am hopeful that when we meet again for the next symposium, two years from now, we’ll have even more scientific and policy progress to celebrate and build on. Thanks to all of the dedicated rotavirus experts who participated and whose work is making a lasting difference in the health and well-being of children everywhere.
Thanks also to the conveners and funders: the Bill & Melinda Gates Foundation, U.S. Centers for Disease Control and Prevention, Christian Medical College Vellore, Indian Council of Medical Research, National Institutes of Health Fogarty International Center, PATH, ROTA Council, Sabin Vaccine Institute, Bharat Biotech, GlaxoSmithKline, Merck Pharmaceuticals, Serum Institute of India, Ltd. and WHO.
Learn more about how rotavirus vaccines can improve health and save lives at www.ROTACouncil.org.