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Johns Hopkins Bloomberg School of Public Health


Date: May 2012

By Adam L. Cohen

The operator of a clean cookstove cooperative in Mulanje, Malawi.

The operator of a clean cookstove cooperative in Mulanje, Malawi. Photo by Matt Feldman / IVAC.

When I moved to South Africa a year and a half ago to work for the U.S. Centers for Disease Control and Prevention on surveillance for pneumonia and influenza, I didn’t realize how much pneumonia affects communities here. Most of the children in the hospital wards where I work are having trouble breathing, hospitalized with pneumonia. Pneumonia is the leading cause of death among children under five in South Africa and worldwide. Mothers want their children with pneumonia to get better, and public health policymakers want to do what they can to make their country as healthy as possible. But how can we help countries do this? There are multiple, proven interventions to prevent and treat pneumonia, but it can be difficult to get these interventions to the people who need them most. At the CDC, we set out to examine the opportunities presented by the delivery of preventive measures, such as childhood immunization, to explore practical approaches for integrating other interventions to treat and control pneumonia in children. Our complete findings are published in the Bulletin of the World Health Organization.

With so many existing methods of reducing the burden of childhood pneumonia, there are exciting opportunities to integrate multiple approaches to improving child health. But there are also many challenges. Most children have access to basic immunizations—could we use this to help protect the children of the world against pneumonia? Globally, many routine vaccination programs are strong, which means that huge strides could be made in pneumonia prevention and treatment by integrating interventions like pneumococcal and Hib vaccinations, zinc distribution, and caregiver education with routine immunizations.

Neither vaccination nor case management alone is enough to eliminate child pneumonia deaths, owing in part to the large number of bacteria and viruses that cause pneumonia. Other important interventions include caregiver education, referral to health care facilities during routine immunization visits, zinc supplements, HIV testing, and the promotion of health behaviors such as breastfeeding, proper nutrition, hand-washing with soap, and the reduction of indoor air pollution.

However, not all interventions are easily distributed, like cleaner burning but bulky cookstoves, and overburdening community heath workers could cause frail health systems to falter or break. There are few of us in the field of public health working to evaluate the integration of multiple interventions. Further, integration of service delivery would require coordination and cooperation across the entire range of donor organizations, NGOs, and governmental ministries.

To address these challenges, we must conduct small-scale studies that elucidate best practices and evaluate the impact of integration before scaling up to large national programs. This will help us empty the hospital wards in South Africa and worldwide.

Dr. Adam L. Cohen is the Influenza Program Director at Centers for Disease Control and Prevention in Pretoria, South Africa.

By Orin Levine

This week in Geneva, health ministers from governments around the world will meet at the 65th World Health Assembly (WHA) for their annual meeting to discuss health issues that affect everyone everywhere. For those of you unfamiliar with this assembly, it’s a bit like a parliament of health ministers. They meet, discuss pressing health issues, put resolutions to the floor and vote. Among the resolutions they will consider is one supporting the Global Vaccine Action Plan, a road map to ensure that by the end of this decade, every child, everywhere enjoys the full benefits of immunization.

The plan is the cornerstone of work to date of the Decade of Vaccines Collaboration, sponsored by the Bill & Melinda Gates Foundation and chaired by global health leaders Ciro de Quadros (Sabin Vaccine Institute), and Pedro Alonso (Universidad de Barcelona). This impressive document is the result of an 18-month consultation involving more than 1,100 stakeholders from 142 countries. The plan sets ambitious new goals for the decade, establishes strategic objectives and identifies the actions that will support their achievement. Perhaps most importantly, it puts developing countries at the center of the plan and stresses country and community ownership of immunization programs as a key pillar for success in the decade ahead.   

As a member of the DoV Collaboration’s Steering Committee, I’m pleased to see the plan reaching the WHA this week. It represents a huge collective effort. But it is also important to remember that global health is full of plans for this and plans for that. The endorsement of the plan by the WHA should be viewed as the beginning, not the end of our work. Turning the document into actions that move the needle on research, vaccine access, and ultimately, child survival will require continued investment and commitment of everyone from lab scientist to front line health worker and from head of state to head of household.

As Save the Children notes in a paper published this month, we’ve succeeded in delivering a full package of most basic childhood vaccines to four out of five children born on the planet, but nearly 20 million children remain incompletely immunized. Children whose mothers have received no formal education are only half as likely to get vaccinated as those whose moms have a secondary education, for example, and rural children are just under half as likely to get immunized as those living in urban areas. In an era where cell phones, soft drinks and Facebook are ubiquitous in every corner of the world, we can and should work to overcome inequalities to ensure that the same can be said for life-saving vaccines. 

The plan outlines clearly the ambitious but achievable goals of the Decade of Vaccines: achieving a world free of polio; meeting all global and regional disease elimination targets; meeting vaccination coverage targets in every region, country and community; developing and introducing new and improved vaccines and technologies, and exceeding the Millennium Development Goal 4 target for reducing child mortality.

We have our work cut out for us, to be sure – and achieving these goals will require that we all do our part, and that we go beyond even Ministers of Health to engage other stakeholders and communities.  Specifically:

  • Countries must commit to immunization as a priority, and work to strengthen their immunization systems
  • Families must understand the value of vaccines, and demand immunization as both their right and responsibility
  • Manufacturers must continue to innovate and deliver quality supply at affordable prices
  • Donors and governments must ensure funding for immunization programs is predictable and consistent, and
  • We must all work together to ensure that the benefits of immunization are equitably extended to all people.

I’m hopeful the ministers present at the WHA will approve Global Vaccine Action Plan this week in Geneva. But I’m even more focused on what happens when the Ministers go home and how the effort engages stakeholders beyond national governments. In a world where corporations, foundations, and non-governmental organizations can be as powerful as some governments, a winning plan for the Decade of Vaccines will require including all the players who can help to achieve this common goal. With all the players involved, and a sustained team effort, it should be a winning game plan. 

Dr. Orin Levine is the Executive Director of the International Vaccine Access Center.

Cross-posted at The Huffington Post.

By Dr. Hope Johnson

Children in Phalombe, Malawi

Children in Phalombe, Malawi. Photo by Matt Feldman / IVAC.

Understanding the major causes of child mortality is essential to establish health priorities and improve the health of children globally. Over the past decade, WHO and UNICEF’s Child Health Epidemiology Reference Group (CHERG) has strived to meet this need by publishing national, regional, and global estimates of the causes of child mortality. This information has been crucial to the development of child health interventions and long-term child survival strategies. 

Since CHERG’s first report, estimation methods and the quality and quantity of child mortality data reported by country vital registration systems have drastically improved. This week, a new CHERG report presents for the first time annual disease-specific time trends for causes of child mortality over the past decade. 

The new data, published in The Lancet, show that child mortality fell by 2 million deaths, from 9.6 million to 7.6 million between 2000 and 2010. According to CHERG, declines in mortality over this period are likely due to improving socioeconomic factors and the successful implementation of child survival interventions in developing countries, particularly those targeting nutrition.

But what continues to claim the lives 7.6 million children around the world every year? Infectious diseases are the main culprits–responsible for 64% of all deaths in children under five. And notorious killers, pneumonia and diarrhea, remain important causes and together were responsible for more than 2 million deaths in 2010. Sadly, a striking 40% succumb within the first month of life most often due to complications related to preterm birth.

Despite the historical drop in mortality seen between 2000 and 2010, the current rate of mortality reduction is insufficient to achieve the fourth UN Millennium Development Goal (MDG4): reduce the child mortality rate by two-thirds, before 2015.

Rapid introduction and scale-up of existing child survival strategies focused on infectious and neonatal causes, particularly in high burden areas of Africa and southeast Asia, is critical for achievement of MDG4. There’s reason to hope, however, with the continued rollout of life saving vaccines for pneumococcal disease and rotavirus by GAVI Alliance and its partners at an unprecedented pace, and at a price low-income countries can afford. But vaccines alone won’t stop pneumonia and diarrhea–other proven interventions such as improved nutrition, appropriate antibiotic treatment, and breastfeeding are also essential elements in this fight.

This newest CHERG report provides a valuable picture of the current state of child mortality worldwide. The data will allow policy makers to prioritize introduction and scale-up of effective interventions to reduce child mortality. CHERG’s job, however, is not over: monitoring the evolving causes of child deaths will continue to be a crucial part of global efforts to erase the 7.6 million child deaths that still occur each year.

Dr. Hope Johnson is an Epidemiologist at IVAC.