Skip Navigation
Johns Hopkins Bloomberg School of Public Health


Date: Mar 2012

By David R. Curry

WHO Vaccination Clinic

Villagers line up to be vaccinated against Smallpox at an outdoor clinic, Côte d'Ivoire, 1970s. From the WHO Archives.

In February, 2012, I participated in the WHO Extraordinary SAGE meeting in Geneva, called to review the Global Vaccine Action Plan (GVAP) being developed by the Decade of Vaccines Collaboration (DoVC). On the flight back to the U.S., I was reflecting on the continuing challenge of identifying and scoping "game changers" in the GVAP to help realize the DoV’s ambitious vision: 

The vision for the DoV is a world in which all individuals and communities enjoy lives free from vaccine-preventable diseases. Its mission is to extend, by 2020 and beyond, the full benefits of immunization to all people, regardless of where they are born, who they are, or where they live.

We need “game changers” because of the scale of the challenge, to be sure. But I was also reflecting on the history of global immunization strategies and that we have faced the same core challenges for generations.

Having arrived early for the SAGE meeting, I spent a day in the WHO Archives pursuing the broad question of when the WHO first considered anything like a global immunization strategy, and at least one other reference point for perspective. Two original documents caught my attention.

The first was a report from what appears to be the first expert consultation on this theme: the first session of the Expert Committee on Maternal and Child Health, Geneva, January 1949. The session title was Immunization Against Principal Communicable Diseases of Childhood - Plan for an International Program (WHO/MCH/5).

The meeting report surveys the then-current knowledge on immunization – informed by WWII – and includes a key recommendation for convening an "international expert conference on immunization procedures as soon as possible. This conference should bring together epidemiologists, paediatricians, heads of child-health services, and experts responsible for the preparation of vaccines in state and other official laboratories and institutes. The conference should discuss the use of the newer techniques for producing the more effective vaccines (e.g. pertussis vaccine) and plans for their widespread application in immunization programs..." The proposed conference was later convened as a result of a resolution adopted at the Second World Health Assembly.

But in the meeting report, the assessment of immunization and its challenges in 1949 (as thinking about an international program was just underway) was alarmingly "current":

"Where immunization programmes have failed, the main reasons for such failure have been 1) a false sense of security when the incidence of these diseases happened to be low, although the population has not yet been adequately immunized; 2) Lack of adequate health education of the public; 3) Insufficient information among the medical professions as regards new immunization procedures; 4) Reluctance to use auxiliary personnel for mass immunization; 6) Lack of appropriate immunization agents [vaccines]; and 7) Lack of appropriate legislation and funds for immunization programmes."   

A companion recommendation was the release of a circular letter by WHO to all WHA members surveying "active immunization" programmes, including an inventory of which diseases and what age groups might be involved in either "advocated" or "compulsory" immunization, whether the country's programme was "assisted by an organized public information campaign," and whether the public is "generally eager for immunization, passive, or reluctant..."

The second reference point comes from a 1974 Consultation on the WHO Expanded Programme on Immunization held at Geneva (VIR/74.15), obviously very early in the EPI era. The report notes:

"...most diseases against which vaccines are available are still uncontrolled in virtually all developing countries. The principal problems are a) lack of trained personnel (and often the idea that only physicians or highly trained nurses should administer vaccines); b) use of complicated immunization schedules appropriate to developed countries but which do not recognize the local epidemiological and administrative realities of the developing world; c) the high cost of equipment and difficulties of maintenance of e.g. transport, refrigeration and jet injectors; d) the cost of many of the vaccines, and e) restrictions on the production of some vaccines because vaccine strains or methods have been patented."

Later in the report, two additional factors around "shortcomings in immunization activities" caught my attention: that “cost benefit and cost effectiveness analyses are either not appreciated by health planners and administrators, or have not been undertaken...” and that “illiteracy and poorly developed public information media result in the lack of public understanding of the need for immunization..."

Finally, this 20-page analysis concludes with a series of recommendations for the year ahead, asserting: "Immunization must be recognized as an essential and permanent programme for the control of communicable diseases and must be a primordial responsibility of the country concerned. The role of the WHO is to stimulate countries to set up immunization programmes and to assist them in doing so..."

These two reference points – from over 60 years ago and almost 40 years ago – are, in a sense, humbling. But they also are a fresh call-to-action. Now is the time to focus our energies and stretch our collective imagination to complete the GVAP with critical game changers, and boldly implement it in the decade-plus ahead. Now is the time for us all to commit our generation to realize the DoV vision.

David R. Curry is Executive Director of the Center for Vaccine Ethics and Policy, a joint program of the Penn Center for Bioethics, the Wistar Institute Vaccine Center, the Vaccine Education Center of the Children’s Hospital of Philadelphia.

By Dr. Dagna Constenla

Few illnesses have as much power to cause panic among the population as meningococcal disease. And the facts are scary: meningococcal disease is one of the most severe and rapidly progressive community acquired infections. At any given time, 10 to 25 percent of the global population carry meningococcal bacteria in the back of their throats or in their noses, but this percentage may be much higher during an epidemic. Up to 20 percent of patients who come down with the disease die, typically within 24-48 hours of the onset of symptoms. The disease, which infects the membranes of the brain and spinal cord, is debilitating and potentially fatal for children, adolescents and people living in overcrowded conditions. And while meningococcal disease is considered a disease of mandatory notification in most countries, the exceedingly low rates of the disease reported by some countries and the high proportion of meningitis reported by others send conflicting messages about its real burden. Information about the true burden of this disease is usually neither published nor easily accessible.                  

What can we do about it?

Today, I write from Buenos Aires, where Latin American researchers, economists and global health leaders have gathered to focus on meningococcal disease in the region 181 experts attended the meeting, representing 21 countries. Latin America has high meningococcal-associated morbidity and mortality, even in the face of early therapeutic intervention. But we still need to have a greater understanding of the true burden of meningococcal disease in the region so that we can help promote programs and introduce vaccines to fight this killer.

Our work on this project, coordinated by the Sabin Vaccine Institute in partnership with the Pan American Health Organization, the International Vaccine Access Center at Johns Hopkins University and the Centers for Diseases Control and Prevention, set out to accomplish two primary goals: to estimate the burden of disease in the region by reviewing available epidemiological data on meningococcal disease in Latin America and the Caribbean (LAC); and to estimate the costs associated with management of meningococcal disease cases and outbreaks in selected countries of the LAC region.

Through this first-ever study, by estimating the burden and costs of meningococcal disease in Latin America, we can begin to determine what obstacles impede its prevention through vaccination.

What did we find?

This is the first study in the region to estimate the cost of meningococcal disease, and the numbers are striking, giving us new urgency for our work: Meningococcal disease incurs a considerable societal economic burden in countries of the region, generating up to $6,228 (USD) in costs per patient. This burden represents the cost of treating an endemic case, not a case during an outbreak.

A detailed socioeconomic study during the 2007 epidemic in Burkina Faso showed that each case of meningitis in a family results in a sudden expenditure of about US$90—what amounts to three or four months of the family's disposable income. Families with few resources cycle inexorably downward to the next level of poverty. In addition, about 25 percent of survivors have permanent after-effects such as deafness, leaving them less likely to be economically productive citizens, and they often become wards of an already financially stretched extended family. Furthermore, what is not captured in the above analysis is the chaos to health systems engendered by a meningitis epidemic.

Closer to home, in Brazil, one community had a meningitis outbreak causing nine cases and spent $143,000 (USD) on investigation and outbreak management alone. This study did not consider the cost of treating the outbreak cases, which would bring the costs of the outbreak even higher. The new study concluded that more and better information is needed to help control outbreaks.

What’s next?

Given the availability of new highly effective vaccines, better epidemiological information, carriage studies and characterization of N. meningitidis isolates are critical to understand the epidemiology of meningococcal disease in Latin American countries.

Along with understanding the biology of disease itself, we must also examine the economic impact, which can vary widely across countries in the LAC region. An economic study is one way of providing such information. Yet what is clear from our research is that coordinated vaccination programs would not only significantly reduce outbreaks, but would also reduce the overall financial burden the disease can have on local health systems.

Our work concludes that through improved surveillance and better understanding of meningococcal epidemiology and costs, we can help devise meningitis vaccination programs that can not only save lives but also prevent these extraordinary economic impacts.

We can eliminate meningitis as a public health problem in the LAC region by increasing awareness of the disease and economic burden, and through the development, testing, introduction, and widespread use of meningococcal vaccines.


The meeting has received plenty of great attention! Here are just some of the many links that have appeared in Latin American media:

Dr. Dagna Constenla is the Director of Economics & Finance at IVAC.

By Dr. Dagna Constenla

Dengue, also known as breakbone fever, is a painful and sometimes fatal disease spread by the bite of a mosquito. Patients that get dengue fever often have painful headache, skin rash and debilitating muscle and joint pains. In some cases, it can lead to circulatory failure, shock, coma and death. Though early and effective treatment can ease symptoms, there is no specific cure available for dengue. Because the mosquito bites all day and can breed even in small bits of stagnant water, efforts to control dengue by preventing bites and breeding are often expensive and provide limited relief.

A vaccine is coming though. After more than 60 years, the development of dengue vaccines has accelerated dramatically. Today, several vaccines are in various stages of advanced development, with clinical trials currently underway on five candidate vaccines. Trials in the most advanced stages are showing encouraging preliminary data, and the leading candidate could be licensed as early as 2015.

Controling dengue by preventing bites and breeding is often expensive and only provides limited relief. A dengue vaccine could prevent illness and change the disease landscape in Latin America and beyond. Photo: CDC/James Gathany

But unlike a new iteration of an existing vaccine, this is uncharted territory. How do we predict its use? Its cost? Cost-effectiveness? Its affordability? How will countries introduce it? To lay the groundwork for the vaccine's eventual introduction, experts from the Latin America and Caribbean region are gathering in Baltimore on March 6-8, 2012 not only to ask questions, but to develop guidelines and standards for costing dengue so that over the next decade, local, and regional decision-makers will have access to robust information on the true cost of dengue in endemic countries of the region.

As a core partner in the Dengue Vaccine Initiative, the International Vaccine Access Center (IVAC) at Johns Hopkins University is pleased to be hosting this workshop in partnership with the Pan-American Health and Education Foundation (PAHEF). For 3 days, more than 15 experts in health economics and epidemiology will work to assess the current evidence of dengue economics research, identify methodological strengths and weaknesses of this evidence, and foster consensus, where possible, on the best way to conduct dengue economics research.

In order to make this work valuable to the entire Latin American region, the guidelines and outputs from this workshop will be made available in Spanish, Portuguese and English on the internet in the months ahead. And then the real work begins. Putting these guidelines to use so that we can improve the evidence-base for decisions in Latin America on how to use dengue vaccines. 

Dr. Dagna Constenla is the Director of Economics & Finance at IVAC.