This post originally appeared on the Nigeria Health Watch and is cross-posted here with permission.
By Chizoba Wonodi
Nigeria launched the introduction of the pneumococcal conjugate vaccine (PCV)into its childhood immunization schedule in Lokoja, on December 22nd 2014. PCV prevents one of the deadliest bacterial causes of pneumonia, meningitis, blood infections and middle ear infections in children. Before now, only parents with the means could afford to vaccinate their children for thousands of naira in private clinics. But now, government is offering it for free to all kids. This is a big deal, so get excited!
Launch of PCV Vaccination in Lokoja
A journey that began 6 years ago has finally come to a successful end. But it was not an easy ride. As I think about the road to this introduction, I remember all the twists and turns along the way and marvel at the tenacity and perseverance of the chief actors in this story.
In 2008, I was working for a Johns Hopkins project called PneumoAdip, which was set up to accelerate the introduction of PCV into African and Asian countries. You may wonder why anyone needs a project to do that, right? Well, it turns out that having a vaccine that works is not enough to get countries to use it, unless the vaccine is for Ebola. I bet countries will scramble for an Ebola vaccine, if it comes. But then most diseases are not like Ebola. For more silent diseases like pneumonia, it takes concerted effort to make the decision makers recognize the burden of the disease, the value of the vaccine and the actions to take on it. For example, it took Nigeria 21 years to adopt the Haemophilus Influenza b (Hib) vaccine into our routine system. The first country to use Hib vaccine in their national program started in 1991, we started 2012.
I remember sitting in the Premier Hotel Ibadan during the 39th Annual General and Scientific Conference of the Paediatric Association of Nigeria (PANCONF) in January 2008. The halls were packed, the place was buzzing, the energy was infectious, pediatricians were milling around discussing how to save babies. I had come from Baltimore to field test a pneumonia diagnostic tool and discuss the prospect of Nigeria introducing PCV into the national immunization program.
At one of the session breaks, I cornered Dr. Abanida, then Director of Immunization at NPHCDA and asked him, “Doc, when are we going to introduce penta and PCV?” “Very soon” he replied, “We will apply for both vaccines this year”. This was an unexpected and pleasant surprise. I had predicted he would commit to only penta, but PCV as well? That was great. You see, it was no coincidence that we were coming late to the penta party when countries like Kenya had introduced the vaccine 8 year before. As a country, we had been preoccupied with battling polio, especially after the major polio vaccine rejection of 2004. In addition, our systems were weak. Indeed, before 2005, we would not have been able to apply for Gavi support for new vaccines even our immunization coverage was less than 50%, less than the required threshold. To get Gavi’s help, countries have to meet certain eligibility criteria and they have to formally apply and be approved for support.
Just as Dr. Abanida had declared, in April 2008, Nigeria tendered their first Gavi application for penta and PCV introduction support. In June 2008, the reviewers granted the application a conditional approval.
Disappointed but not deterred, in September 2008, the new vaccine application team led by Dr. Oteri, then Gavi desk officer at NPHCDA, responded to the conditions and queries from Gavi. But the second submission was rejected and the country was asked to re-apply.
Three things then happened that delayed the process for the next two and half years. First, Gavi suspended all new vaccine applications due to internal processes and funding constraints. No country could apply for new vaccine support in 2009. Second, Gavi revised their new vaccine application policy, now requiring an immunization coverage rate of at least 70% instead of 50%. Third, Nigeria’s vaccine coverage dropped below 50% to 42% according to WHO-UNICEF estimate released in June 2010. This new drop caused Dr. Dorothy Esangbedo, then the President of the Pediatric Association of Nigeria, to lament bitterly and call for stronger action to shore up routine immunization.
Under the new policy and with the lower coverage, Nigeria could not re-apply in 2010. In fact, a workshop in August 2010 convened by NPHCDA to develop the third submission was truncated by the twin news that our coverage rate had dropped and Gavi coverage requirement had increased.
When Gavi began revising their policy, there had been talk and expectation in some quarters that countries such as Nigeria, who were already in the application process before the policy change, would be “grandfathered in”. That did not pan out. To help matters, Gavi delayed the implementation of the new coverage requirement by one year, which left Nigeria with one window of opportunity to apply in May 2011.
But there was one more hurdle to scale. Coverage estimates for 2010 had to be 50% or better. The National Immunization Coverage Survey (NICS), showed coverage to be 71% for 2010, but Gavi only recognizes the WHO/UNICEF estimates, which was still 42% and would only be updated in July. Nigeria needed the updated estimates to apply in May. The update would be two months late. What to do?
The emails and phone calls started going back and forth advocating for a solution. At IVAC we pushed for different options: allow Nigeria use the NICS to apply, allow a phased introduction, so that states that meet the coverage criteria can be supported to introduce the vaccine, while effort be made to raise coverage in the other states. Dr. Mohammad Ali Pate, then Minister of State for Health, was very vocal in his advocacy to find a solution. Eventually and exceptionally, Gavi allowed Nigeria to apply for penta and PCV in May 2011. Then in July 2011, penta was approved and PCV was conditionally approved. All decisions were subject to the 2010 WHO/UNICEF DTP3 coverage estimates being >50%.
After the July 2011 conditional approval for PCV, Nigeria worked on responding to the conditions attached to the approval by strengthening the cold chain system. Then, 15 months later, in October 2012, Gavi gave the final approval for a phased roll out of PCV to begin in 2013. However, due to global supply constraints and other operational issues such as strikes in the Nigerian health sector, the first child could not be vaccinated till December 2014.
I didn’t go for the launch, but my colleagues went, and it was gratifying to see the culmination of everyone’s effort. Big thanks should go to the NPHCDA, Gavi, UNICEF, WHO, Pediatric Association of Nigeria, CHAI and all other groups who have pushed hard to see this happen.
First Nigerian Child to receive the Free Pneumococcal Conjugate Vaccine
As I look at the grainy picture of baby Collins, who is the first child to be vaccinated, cry out in pain from the shots of the first PCV vaccination, I wish I could tell him,
“Baby, don’t cry, laugh instead, even though that injection is painful. You are getting a shot a life. Something that babies before you did not get, but thankfully those after you will receive. If we are able to immunize 87% of your fellow babies every year with this vaccine, we can save about 200,000 lives by 2020. Isn’t that something to laugh or even rejoice about? Yes indeed, it is cause for celebration. I only wish it didn’t take six long years for this to happen. Think of all the babies we could have saved in that time. Anyway, you are too young to understand all this. After all, what do you know? You are just a baby. You probably just want to suck you mother’s breast right now, forget all this noise and go to sleep. So I’ll let you be.”
Dr. Chizoba Wonodi (MBBS, MPH, DrPH),
Nigeria Country Programs Lead, Johns Hopkins International Vaccine Access Centre,
Advisor, Saving One Million Lives Initiative,
Advisor, Gavi’s Strategic Demand Forecast for vaccines.
This post originally appeared on the VaccinesWork blog and is cross-posted here with permission.
By Huma Khawar
In 2012, Pakistan was the first South Asian country to introduce the pneumococcal vaccine with Gavi support. Provided free of charge to children under the age of five, the vaccine protects against a major cause of pneumonia, a disease that is a major killer of children worldwide. But in order for any vaccine programme to be successful, information and support are essential. And where do many people get their information? The media.
The question and answer session in action. Photo: Huma Khawar
Dr Taimoor Shah, Deputy Director Khyber Pakhtunkhaw province’s Expanded Programme on Immunization (EPI), knows this well. On World Pneumonia Day last November, he took the opportunity to gather a room full of journalists of all backgrounds at the Press Club in Peshawar, to talk specifically about the pneumococcal vaccine and to answer their questions.
The result was a discussion that sounded more like a medical classroom than a group of reporters. How many vaccines are included in a child’s immunisation programme? What are the diseases that can be prevented through immunisation? How expensive is the pneumonia injection? It was difficult to decide whether to feel surprise at the lack of awareness among the media about vaccine preventable diseases or to be happy at the eagerness and genuine interest expressed in the reasons for Pakistan’s high rates of child mortality.
The session was both informal and interactive. Journalists from different organisations suggested ways to educate people on vaccination and eradication of fatal diseases through media messages. They concluded that it was the common duty of parents, government health institutions, media and civil society to take steps for overcoming health issues through vaccination and timely treatment.
One journalist confessed that although he knew all about how and when to give the different vaccinations, he didn’t know the importance of each. ”It will be easier, he said, to convince mothers on the importance of getting their babies immunised.”
The session also gave the health journalists an opportunity to express their own opinions and share insights. They talked openly about how, over the years, with so much money and emphasis directed towards polio eradication, routine immunisation had taken a backseat.
By the end of the session, some 30 plus media personnel had learned much more about vaccines and routine immunisation. One digital reporter admitted that this type of question and answer sessions was essential as a vast majority of journalists have limited knowledge of vaccines and their potential.
“A lot of mothers get their information from newspapers. Media should be up to date. If their knowledge is suspect, they will pass on wrong information to parents. This can be very dangerous,” he said.
And in a country where each year one in twelve children born die before reaching the age of five, many of them due to vaccine-preventable diseases, spreading this newfound knowledge can only be a good thing.
Photo: Humar Khawar
Huma Khawar is a freelance journalist and IVAC communications consultant who works in Pakistan.
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.