IVAC Blog

By Lois Privor-Dumm

It’s not often that themes for meetings are really meaningful, but the RISE (Results, Innovation, Sustainability and Equity) theme of the GAVI Partners’ Forum last week in Tanzania really rang true to the work that is being done. I felt proud to be a part of the progress being made and for IVAC’s role in advancing the four RISE principles. 

Lois Privor-Dumm, MIBS

For example, last week IVAC had the opportunity to continue progress on an ongoing project related to supply chain and decision-making innovation by following up with many partners who attended a primary container roundtable we organized in May 2012 where we reviewed the available evidence on vaccine containers and developed a framework for improving decision making. Building on the discussions from that meeting, we met at the Forum to review an exercise of the HERMES (Highly Extensible Resource for Modeling Supply-chains) modeling system that Bruce Lee and his team from University of Pittsburgh conducted in Benin along with in-country partners including AMP. Colleagues from GAVI, the Bill & Melinda Gates Foundation, UNICEF, WHO, John Snow, Inc., Clinton Health Access Initiative, manufacturers and others joined us at the crack of dawn to review the results of the Benin pilot and provide feedback on the exercise. 

On the surface, decisions about which type of vaccine container to use don’t seem that complicated, but implications are far reaching. We discussed the more obvious implications including changes in procurement, logistics costs and cold chain space, which are relatively well understood. We also took the conversation a bit further, looking at the effects of vaccine hesitancy and availability on coverage. For example, if a health center has large vial sizes and only one or two children are scheduled to visit that day, a health worker may hesitate to open a new vial, thus missing a vaccination opportunity and reducing coverage. On the other hand, if the health worker does open the vial, the rest of the vaccine may be wasted, which could reduce vaccine availability for children who visit the center in the future. The complexities of these decisions become clear after a closer look.

We also discussed the safety considerations that come into play, particularly with new products coming down the pike. We agreed on the importance of bringing visibility to competing tradeoffs to ultimately help countries, donors and manufacturers make better decisions. Highlighting the impact of container decisions can help countries evaluate and consider other options for their cold chain, as well as appreciate the impact that various policies to minimize waste or lower cost might have on how many vials are opened and how many children are vaccinated.

Diagram of an optimal vaccine container.

It was a productive meeting, and I look forward to our joint commitment to find solutions to complicated issues and focus more on the system and how it impacts our ultimate results. Better decisions will lead to better product availability, guidance for manufacturers regarding country needs, better policies and more efficient systems. The process may be labor intensive at first, but the investment into getting it right and reframing how decisions are made can pay off multifold.

Lois Privor-Dumm, MIBS, is Director of Alliances and Information at IVAC. She oversees IVAC’s advocacy and communications efforts, large country programs, and special initiatives such as the primary container project.

By Dr. Sachiko Ozawa

Evidence on the value of vaccines is essential for donors and government officials to see what their investment in vaccines buys. This value isn’t only about the health impacts we tend to think of – such as lives saved, illnesses prevented, and disability averted from vaccines. Vaccines also bring about broader economic benefits. Families avoid treatment costs and parents do not have to take off from work to care for sick children. Children may also have fewer missed school days, succeed better in school, and take on higher-paying jobs to support the country’s economy. In short, vaccines are likely to bring much value beyond direct health impacts.

Sachiko Ozawa, PhD, MHS

Last week I participated on a value of vaccines panel at the GAVI Partners’ Forum that focused on just this idea. Raymond Hutubessy from the World Health Organization introduced the importance of valuing the full value of vaccines. I then presented the current evidence base including a recently published literature review from IVAC, which demonstrated that vaccines are cost-effective but highlighted the need to strengthen the economic data on vaccines. Till Barninghausen from the Harvard School of Public Health and Damian Walker from the Bill & Melinda Gates Foundation shared results from two case studies in South Africa and Bangladesh. These studies found that the measles vaccines can increase school attendance and improve school attainment (as measured by higher test scores), which may lead to a higher earning potential for these children.

We were pleased to have a truly engaged audience. The audience recognized that cost-benefit analyses that present the benefits of vaccines in dollar values are useful and needed, which is a contrast from the current norms to use cost-effectiveness data that assigns a dollar amount per DALY or disability-adjusted life year averted. An argument was made that just as interventions in other sectors could save lives, we need to present the benefits of health interventions in the same financial terms these sectors would use, in order to show the full return on investment. It was also noted that we are not done building the evidence base around the narrow benefits of vaccines. Therefore, a suggestion was made that we build economic evidence both at the narrow and broad levels concurrently. Another point made at the session was that many of these broad benefits may result not only because of vaccines, but because of a combination of health interventions that save lives and prevent illnesses. Audience members suggested looking into measuring the economic value of a package of interventions, or of a healthy child as a whole, in order to support efforts to advocate for investment in health vis-à-vis other sectors.

This successful panel and discussion led to an unexpected and truly exciting opportunity. Our panel was called upon by about 25 parliamentarians participating at the forum to give a separate presentation to this honorable group. This meant we could disseminate our work to the people who are actually advocating for vaccines in low- and middle-income countries. What an opportunity! We took to this occasion with enthusiasm and received feedback from the parliamentarians that confirmed they need evidence in dollar values to take to their ministers of finance. Many members of parliament in the room said they were glad to be armed with more evidence they can use to advocate for vaccines. We truly hope this type of engagement will continue with parliamentarians beyond this forum.

At IVAC we pride ourselves on being able to create, model and develop evidence that could be used in decision-making. Last week I witnessed that the evidence we develop indeed matters to audiences who use it to advocate for improvements in child health. Beyond the opportunity to share our evidence with parliamentarians and receive their feedback, I saw the economic evidence we developed put to use in advocacy materials such as an infographic created by the United Nations Foundation’s Shot@Life campaign.

One statement at the forum stuck with me: “Advocacy without evidence is just opinion.” I look forward to continuing to build the economic evidence that can be used by advocates – work that truly matters to saving children’s lives.

Sachiko Ozawa, PhD, MHS, is an Assistant Scientist with Johns Hopkins University Bloomberg School of Public Health and IVAC.

By Dr. Kate O'Brien

This week, IVAC staff have had the privilege to participate in the GAVI Alliance Partners’ Forum in Dar es Salaam, Tanzania. This could not be a more fitting choice of location, as a country that has shown remarkable leadership and commitment to vaccines for children. Yesterday (December 6th) marked the dual launch of rotavirus vaccine and pneumococcal conjugate vaccine in Tanzania, the second country to have undertaken such a dual launch (Ghana being the first).

The Partners’ Forum brings together in one place the truly remarkable range of partners that make up the Alliance including civil society organizations, UNICEF, WHO, GAVI-country representatives, donor country representatives, the Bill & Melinda Gates Foundation, vaccine manufacturers, the World Bank, the Pan American Health Organization (PAHO) and many others, coordinated in their efforts through the leadership of the Secretariat. IVAC, and numerous other technical and academic groups, are counted among these valued GAVI partners producing work that really does move the needle.

The theme of this Partners’ Forum is RISE, highlighting Results, Innovation, Sustainability and Equity – four themes that resonate for us at IVAC. I want to particularly focus on the results, without which there is nothing upon which to base innovation, nothing to sustain and nothing driving an insistence on equity.

Throughout this Forum we have seen the power of evidence to propel sound decision-making and commitments that are saving lives and reducing suffering around the world. We saw the power of pneumococcal conjugate vaccine disease impact data from Kenya where in just two years of vaccine use, vaccine type pneumococcal disease is becoming vanishingly rare. We also saw the compelling case for vaccines through the promise of over $150 billion of economic benefits gained over 10 years through improved health by vaccination. And we saw the reassurance of real-world performance and safety evaluations for rotavirus and pneumococcal vaccines in settings around the world where the vaccines are most needed.

Photo Credit: Excerpt from Shot at Life's Economic Value of Vaccination Infographic. Based on Decades of Vaccine Economics (DoVE) research from IVAC showing that increasing access to coverage with new and existing vaccines can yield substantial health and economic benefits (Stack, et al. Health Affairs - June 2011).

These results meaningfully strengthen the foundation of evidence on which these vaccines stand. Speaking for themselves, these data bring renewed energy, commitment and resolve that the extraordinary effort by hundreds of thousands of community health workers, nurses and doctors to get these vaccines into children, on time for every dose, will indeed deliver results.

IVAC is proud to have collaborated with various organizations, both in country and internationally, to generate the results highlighted above. These particular studies are a great example of how we all stand shoulder to shoulder with our partners, and our partners’ partners, to make vaccines real for children, families and communities. Through the GAVI Alliance we have had the opportunity to work in trusted collaboration with PATH, CDC, Aga Khan University, University of Witwatersrand, Norwegian Institute of Public Health, KEMRI Wellcome Trust, WHO, PAHO, MRC Gambia, South Africa’s National Institute of Communicable Disease, and many other institutions on projects, studies, evaluations, trainings, and assessments that are all delivering directly on our shared vaccine mission.

This Partners’ Forum has been a focused opportunity to see compelling results make a difference. It is really happening. As we contemplate what it will take to assure every child is not just vaccinated but fully vaccinated, I urge us all to lean forward together in this effort to ensure change happens.

We at IVAC are committed to Rising to the Challenge with all of you.

Kate O’Brien, MD, MPH is Acting Director of IVAC. A pediatric infectious disease physician, epidemiologist and vaccinologist, she previously served as Deputy Director of IVAC. She also serves as Associate Director of the Center for American Indian Health.

In October, Dr. Kate O’Brien took over as Acting Director of IVAC. One of IVAC’s founders, she reflects here on how far the organization has come and her vision for the future, while also sharing a bit about her diverse career in global health.

You have been at Johns Hopkins University for more than 20 years. Can you tell us a bit about your background and how you ended up at IVAC?

When asked about my background, I find myself saying first and foremost that I am a Canadian, which helps explain who I am and why I do what I do. As a pediatric infectious disease physician, as well as an epidemiologist and vaccinologist, I’ve had the great fortune to work on meaningful problems and with remarkable people. Much of my training and career has been spent at Johns Hopkins where I first came to work as a pediatric intern in 1988. I also did my infectious disease training, and my Masters of Public Health at Hopkins. Following those formal training programs I joined the Centers for Disease Control in Atlanta as an Epidemic Intelligence Service Officer where my career direction was really set in motion, working on pneumococcus, Hib, and other bacterial diseases of childhood. Although over the years I’ve worked on many different pathogens and vaccines, all of that work has been held together by the concept of preventing disease in children, and specifically preventing disease through vaccines. For me an important notion is that throughout the developed world we have the incredible good fortune to live in communities with abundant resources. When it comes to children, vaccines are a social justice issue. Every parent, everywhere in the world wants their child to have a life of opportunity – it doesn’t seem fair, or just, that some kids have the benefit of receiving vaccines and others don’t, by the quirk of where they happen to be born. My work is about assuring not only that we have the best vaccines possible for preventing as much disease as possible, but also that the benefit of those life-saving vaccines should be available to all kids around the world regardless of where they were born, or whether their families can pay.

Dr. Kate O'Brien, Acting Director, IVAC

This is the foundation of IVAC and before that the PneumoADIP project, whose provenance is an interesting story. I had returned to Hopkins from CDC to work for the Center for American Indian Health on vaccine trials [Editor’s note: Dr. O’Brien continues to serve as Associate Director of the CAIH]. Soon after I returned, Orin also came back to Hopkins to join our group after he had spent time at the CDC and NIH. Soon thereafter, the RFP for the PneumoADIP was issued by GAVI; I remember sitting in my office with Orin discussing if I wanted to go in on this, to which I naively committed but warned him that I didn’t know what an “ADIP” was! We submitted a proposal setting out our ideas of how a set of activities could accelerate pneumococcal vaccine decision-making and were awarded the PneumoADIP grant. That was a really stimulating period of time and one that was transformative within the School by bringing together domains of science, finance and communication in a way that was not typical for the kinds of projects Johns Hopkins was doing at the time. Through that project we envisioned a place within the School that worked on vaccines from a multi-dimensional perspective and brought together skills and domains that go beyond the traditional science or academic ways of working. When the PneumoADIP project came to an end we embedded those principles into the founding of IVAC – to use the skills that we have within academia, of unbiased, rigorous, data driven decisions, always being clear as scientists that we allow the data to speak for themselves, and to bring those into the world of policy development and advocacy for vaccines.

You have had quite a varied career within public health. What inspired you to work in global health specifically?

Working in global health for me is really a social justice issue. Growing up in Canada, where the values of contributing to society are very strong, I hold as a guiding principle that all people are precious regardless of their station in life; children especially should not only have the opportunity, but they should also have the right to good health and the right to protection from preventable diseases. So for me the global health sphere is one that really speaks to my values, one that informs what I want to spend my working days doing, and how I want to contribute to society. From a personal perspective, it is a remarkable opportunity to constantly learn from others. It is also a career that demands humility – there are very few concrete “right” ways of solving problems, because there are just so many different ways people make decisions and contribute to health, and so many ways that communities and societies interact to make decisions for the collective good. In all those ways there is always a learning curve, always a way to feel enriched and a great sense of contribution. 

The global health landscape has really expanded in the past several years, and some would say that the space is now crowded. What makes IVAC stand out?

That’s a great question. There are some really clear things that make IVAC special in the global health arena. One is that IVAC is fundamentally seated within a university. Being in an academic setting means the fundamental characteristic of our work and approach is being balanced, agnostic and neutral – the pursuit of new knowledge, the revelations of new learnings, will always lead us in the direction of benefit and good decision making. This philosophy, that the data will speak for themselves, draws people to IVAC as faculty and staff who are committed to letting the evidence drive our efforts. The second thing that makes IVAC unique is that within the university, IVAC is really an unusual center; sitting within a single center are people working in diverse domains of vaccines where interaction with each other on a daily basis doesn’t usually happen. I think this was the incredible lesson of PneumoADIP – when you take people who are experts in financing, strategic vaccine supply, advocacy and communications, and you put them in the same space, thinking about the same problems as the epidemiologists, the vaccine clinical trialists, and the people who are scientifically driven, you end up with a learning space and leveraging of those skills well beyond the sum of the parts. You end up being able to look at problems in the vaccine space with solutions that were otherwise not imagined by any one group of people working on the problem. It is this multi-dimensional characteristic that is unique, and the emphasis and demand for excellence in all we do, which I think is what comes out of the academic atmosphere.

Dr. Kate O'Brien with a child in Bangladesh.

Along those lines, what have been some of the proudest moments at IVAC over the years?

There are many, but what come to mind are several tangible things. Going back to PneumoADIP days, a really proud moment was the launch by GAVI of the Advance Market Commitment for pneumococcal conjugate vaccines. PneumoADIP’s mission for five years was to figure out – in collaboration with the many global partners and country partners who all had views on and interests in this – whether or not pneumococcal vaccine should and could become a reality for the poorest kids around the world. So, the launch of the Advance Market Commitment was really one way when it all came together and became tangible; we knew we had reached a goal. There were many steps, some of them small steps and some of them really big steps, that culminated in an expression that global health decision makers, viewed the evidence as sufficient, credible and conclusive that pneumococcal conjugate vaccine was a product worthwhile to deliver to kids in the developing world and that there was a way of making that happen. So that was an incredibly proud moment and really felt like a culmination. 

Since then, each time a country launches pneumococcal vaccine it is a proud moment because it is an on-going living expression of the value of the work that we have been doing. It becomes something real for me that there are infants and children whose lives have been saved by those vaccines; of course we don’t know which kids they are but we know they are there.

Other proud moments come from the spirit and enjoyment of the people at IVAC and those we work with in partner organizations; there is real motivation by the mission and by the creativity and innovative way that we work. Events like World Pneumonia Day that bring pneumonia fighters to the streets of Washington or events like Pneumonia’s Last Syrah in New York where we sold wine to promote the prevention of pneumonia are really amazing – those are just not activities that the average pediatric infectious disease physician gets to spend time working on!

So looking to the future, what are your top three priorities for IVAC as we move into 2013?

My top priority for 2013 is to continue delivering the highest quality work for every project we’re are engaged in. This is the guiding core value of IVAC and we will continue to deliver the quality of work that we have always delivered.

The second priority is for IVAC to contribute meaningfully to new areas of work---that could be new projects within areas that we’re already engaged in, or completely new areas. Whether it is pneumonia etiology studies, impact evaluations of vaccines, economic and advocacy projects that help decision makers understand the best use of vaccines, or work on prioritization and implementation of those vaccines – there are many areas where IVAC can contribute its expertise to really important decisions.

The final and foundational priority is to assure that the people within IVAC continue to have a supportive atmosphere where their effort is valued and where they know that the work they are doing is making a difference.

Building on that and taking it forward, what does success look like for IVAC in the next five years?

That’s an easy one; success for IVAC is when, five years from now, there is a healthy IVAC. And what I mean by that is IVAC continues its contributions in the global health sphere with people who are working on topics that they feel are important and that the global health community is deriving value from that work. It’s really important that we not be rigid in what that looks like, instead we need to be flexible to address the needs of the community. A successful IVAC in the next five years is responsive to the needs that emerge to actually get vaccines where they need to be and demonstrate the value of those vaccines so they can continue to be supported.

Tell us a little bit about your family.

My husband is an adult infectious disease physician who also works in the global health sphere, but mostly in the domain of HIV/AIDs. We met while working in Haiti. We have two kids, Emma who is 15 and Jack who is 13. My extended family still lives in Canada so we spend a good deal of time there.

As some readers may know, you moved from the Washington, DC-area to Geneva last year. What do you and your family like best about living in Geneva?

Beyond the work we do here what we appreciate most is the incredible access we have to the  outdoors and the stunning beauty of this land. Everyone in our family really loves being in the mountains, being on a bicycle, taking a walk in the woods or through farmland, or skiing or ice-skating. Switzerland is such a small country, it means all of these things are close by. We love having the ability to enjoy this remarkable part of world for however long we are here.

We also really appreciate the opportunity to live in more than one language. Just having that lovely experience of coming into other cultures and into other peoples’ ways of living means we all can learn a lot about better ways of living.

What is the most interesting place that you have traveled to?

I knew you were going to ask me that!

We thought it might be Haiti, since that is where you met your husband.

I should say that, shouldn’t I? In fact Haiti is probably the most interesting place I’ve ever lived. It has an incredible mixture of cultures and histories, the European influence, the African influence – it is really a remarkable and unique culture. The art and the music that comes out of Haiti is phenomenal. It has a deeply troubling and in many ways tragic political history, but in spite of that there is a resilience and love that people have for their culture, for their country and for each other. Another place that is a favorite of mine is Jerusalem. It’s hard not be overwhelmed by the presence of history there.

One last question. You’ve had an amazing career – what are some of the highlights you’d like to share?

The greatest highlight has been the privilege to care for my patients…there are many kids and their families who have touched me in ways that they will never realize. I know this is a common experience for every physician, for every nurse, but it is true. There is far more that our patients give back to us than we can ever give to them, much as we try. The communities I’ve been able to serve are undoubtedly a highlight, in particular the Navajo and White Mountain Apache tribes who I’ve worked with for over 14 years, trying to address health disparities from vaccine preventable diseases. Those communities have a beauty and a history that is deeply humbling, showing us how little we really understand about life and spirit in this contemporary, modern, western society we live in. The other highlight is one that underlies everything, and that is the people I’ve worked with over the years. Those who know me know that beyond all else is my belief that in the end our work, our success, our joy, is always all about the people. Over the years I’ve had the most amazing mentors, colleagues, collaborators and students at Hopkins, at CDC, and at many other organizations around the world. In the end, it is always, all about the people.   

By Dr. Kate O'Brien

Being a doctor doesn’t necessarily make being a mom to a sick baby any easier. Like every mother, I’ve spent my share of sleepless nights tending to my kids sick with a cold, or diarrhea, or an earache, but those episodes are just a distant blur for me. Not so the time my son had pneumonia.

It was his first Christmas and we were both really sick with a respiratory illness that I’m sure was the flu. I kept telling myself we would both feel better soon. But we didn’t. In fact, Jack got worse. By evening and into the night, with more rapid breathing and some tugging of his chest with each breath, there was no question we needed to get him medical care. These were signs that something was very wrong.
     
An x-ray confirmed that Jack had pneumonia. My heart sank. I was supposed to have gotten him vaccinated against the flu weeks earlier, but I put it off. As a pediatrician and vaccinologist, I knew that vaccine could have protected him from pneumonia. As a parent, I should have never have been “too busy” to get him vaccinated. Thankfully with proper treatment, Jack quickly recovered. I knew we were lucky but also knew there were hundreds of thousands of children each year who are not. Read the full blog at Million Moms Challenge.