Your companion on the red-eye from Dulles airport to Geneva is a two inch-thick Yellow Book—478 pages of previous meeting notes, disease eradication plans, reviews of evidence, references, and more related to the meeting of WHO’s Strategic Advisory Group of Experts (SAGE)—including at least seven global policy questions you will need to make a decision about. All this in 30 hours of meetings over three days.
Feeling fuzzy getting off your flight? Grab a double expresso as you are head over to WHO HQ on Avenue Appia. Outcomes of these meetings will inform WHO’s Director-General and lead to new recommendations from WHO for all countries on the best ways to ensure vaccines improve health and save lives for as many people as possible.
Welcome to SAGE!
IVAC's Delegation at SAGE 2017
From October 17-19, three faculty members from the International Vaccine Access Center (IVAC), of the Johns Hopkins Bloomberg School of Public Health (JHSPH), provided technical expertise and leadership at the annual SAGE meeting, an advisory body formed in 1999 to provide guidance on immunizations to the WHO.
IVAC’s delegation included Director of Epidemiology Bill Moss, Director of Science Maria Deloria Knoll, and IVAC Executive Director Kate O’Brien. The meeting, held in the August Room where WHO’s 34-member Executive Board meets, was attended by about 200 people and included presentations from nine Working Groups. SAGE Working Groups delve in to key immunization-related questions of interest to policymakers around the world.
The Executive Board’s elevated screen helps viewers sitting on multiple tiers follow presentations. Maria’s purple sweater helped people locate her in the immense room.
How did IVAC members at SAGE support policy-making for WHO?
Measles and Rubella
Dr. Moss, who also serves as a Professor in the Departments of Epidemiology, International Health, and Molecular Microbiology and Immunology (MMI) at JHSPH, has been a member of SAGE’s Measles and Rubella Working Group since 2011. Dr. Moss presented evidence supporting a recommendation that people living with HIV do not need to be re-vaccinated against measles if they were not infected with HIV at the time of their measles vaccination in young childhood. This policy has implications on the estimated 34.5 million adults living with HIV infection and on the achievement of measles elimination goals.
Dr. O’Brien, who is a Professor in both Departments of International Health and Epidemiology at JHSPH, has served as a SAGE member since 2012 and has participated in multiple Working Groups over the past four years. This year Dr. O’Brien chaired the SAGE Working Group on rabies vaccines and rabies immunoglobulins, which are antibodies that recognize and bind to the rabies virus to destroy it. Sidebar… Dr. O’Brien’s analysis of rabies vaccine policy became personally relevant during a holiday in Mexico: a bat flew into her son Jack’s face and sent them on a complicated journey to locate rabies immune globulin and vaccine (fortunately, they found them both and Jack remains healthy!).
Pneumococcal conjugate vaccine
Dr. O’Brien also co-led the Pneumococcal Conjugate Vaccines Working Group (more about this below). During this meeting, Dr. Knoll, who serves as an Associate Scientist in the JHSPH Department of International Health, presented on a review IVAC authored of over 200 studies assessing the effect of both of WHO’s recommended dosing schedules on vaccine-type disease, or the strains of pneumococcus included in the 10- and 13-valent conjugate vaccines.
Recommendations to WHO Director-General
Dr. O’Brien and the other 14 members of SAGE—each representing a different institution and country—considered the evidence and made formal recommendations to WHO. For example, based on the evidence presented, SAGE concluded that both WHO-recommended PCV schedules have a substantial impact on reducing vaccine-type disease. All evidence presented during the meeting is available in the Yellow Book.
How SAGE gathered evidence to optimize the impact of pneumococcal conjugate vaccines
Starting in January, the pneumococcal conjugate vaccines (PCV) working group, led by SAGE members Dr. O’Brien and Dr. Andrew Pollard of the University of Oxford, reviewed extensive evidence on PCV impact. One of the main sources of evidence was the PCV Review of Impact Evidence (PRIME) Systematic Review, an effort co-led by IVAC with partners including the US CDC, WHO, the University College of London, and Agence de Médecine Préventive. Over the past two years, the PRIME group reviewed studies to assess differences in disease, immunogenicity, and carriage impact by PCV schedule and product, as well as evidence of immunogenicity of catch up immunization. This systematic review served as an update to a previous review conducted by IVAC, which compared impact of different schedules in the context of PCV7 use and served as an important evidence base for previous SAGE WHO PCV recommendations.
Among the PRIME review’s findings on PCV schedules:
Immunogenicity: A 3-dose primary series induces a greater immune response compared to a 2-dose primary series. However, in a 3-dose schedule, the third dose is more immunogenic when given as a booster (2+1) for most serotypes. It is important to note that greater immunogenicity may not necessarily mean better protection from disease.
Nasopharyngeal Carriage: Both schedules showed an impact on overall vaccine serotype carriage (product specific vaccine-type).
Invasive Pneumococcal Disease: Both schedules showed impact on overall vaccine-type invasive disease. For serotype 1, the 2+1 schedule showed clear evidence of impact from a substantial body of evidence; for the 3+0 schedule although some impact was seen the data were more limited.
WHO’s recommendations related to dosing schedule, catch up vaccination, and product usage will be published in a PCV Position Paper in 2018. If there are opportunities to improve impact, countries using pneumococcal vaccines may consider update their schedule and product choices.
In the meantime, we’re clearing off our bookshelf space for the next onslaught of documents… SAGE will re-convene April 17-19, 2018 – see you there!
For more information, see the resources below:
By Chizoba Wonodi, IVAC Nigeria Country Director and WAVA National Convener.
In March we celebrate International Women’s Day, when the world recognizes the achievements and contributions of women of all colors, creeds and credentials. This spirit of empowerment resonates in Nigeria, where the Women Advocates for Vaccine Access (WAVA) are equipping members with small grants to conduct advocacy for sustainable immunization financing.
WAVA is a cross-sectoral coalition of women and women-focused civil society organizations. Members span the length and breadth of the six geo-political zones of Nigeria. While addressing a diverse range of developmental issues, WAVA members make a commitment to advocating for immunization access for all women and children. I’m honored to serve as their national convener.
The first-ever small grants contest was designed to encourage WAVA members to develop and carry out bold, new and exciting strategies to galvanize action, specifically for vaccine financing at all levels. If the plan could get people to listen to our cause and act on it, the idea was considered—even if it sounded crazy.
We could not have anticipated the spectacular array of creative proposals when we launched the small grants program, on the heels of our inaugural investiture ceremony for WAVA Vaccine Champions in December 2016. Ideas ranged from engaging youth in immunization financing discussions to hosting weekly radio shows on immunization.
To provide each proposal a fair review, we assembled a crack team of internal and external reviewers in Abuja and Baltimore. Over a six-week period, five Abuja and Baltimore-based internal reviewers poured through the pages, weighing the pros and cons of one idea against its ability to contribute to our mission. Proposals that scored 70% or higher in the initial review were then sent to at least two out of the three external reviewers.
A well-deserved shout-out goes to our able and excellent external reviewers, Hon. Usman Mohammed, WAVA Champion extraordinaire; Mr. Edwin Ikhuoria, advocate par excellence; and Dr. Francis Ohanyido, jack of all trades and master of all.
Out of sixteen submissions, seven made it to the final round. From this crop, the reviewers chose the top three entries based on their average scores and a qualitative agreement in ranking by both internal and external reviewers. In the end, there were only three winners and I believe the reviewers made the best choices.
To all that participated, know that I am proud of the efforts you put forth in this round. I hope that in the subsequent rounds we will see the same level of enthusiasm—or even higher. Be assured you will get constructive feedback from us that you can use to improve your proposal and grant writing skills for other opportunities. Our unflinching commitment to the growth and success of our members demands that we don't just say, “Sorry, better luck next time.” Rather we feel obligated to give a thoughtful review of the strengths and weaknesses of your submissions.
Our vision is that WAVA members become not only top notch advocates, but also successful and sustainable organizations. Nigeria continues to need our help to ensure vaccine access for women and children everywhere.
This post is part of the #ProtectingKids story roundup. Read all the stories here.
There is a popular saying that you cannot manage what you cannot measure. This is so true for the global effort to close the immunization gap. We need to localize and measure the gap before we can close it. Having good immunization data to evaluate how well we are reaching all children is a critical ingredient for success.
I was poignantly reminded of this fact a few weeks ago when I visited Damangaza community, an urban slum in Nigeria’s Federal Capital Territory, where one of our Women Advocates for Vaccine Access (WAVA) member works. A temporary settlement, Damangaza is made of mud huts, open sewers, zero infrastructure, friendly adults and playful children. This generous community hosts more residents than it can comfortably accommodate, even welcoming internally displaced families fleeing from Boko Haram. A mere 20 minutes drive from the heart of Abuja, the contrast in wealth and access between the community and the nearby Abuja city center couldn’t be any starker.
When WAVA member, Vaccine Network, began working in Damangaza a few years ago, majority of the children had never been vaccinated. The year before, an outbreak of measles swept through the community killing many children in its wake. Although by no means hard to reach, a community like this is one of many settings where children easily fall through the cracks and are missed by immunization services.
Little wonder current data shows that one in five African children is under-vaccinated. If we are to reach that fifth child, we need accurate and timely data to tell us who that child is, where they live and why they are missed. This is a big challenge in Nigeria where the two main sources of immunization data (survey and administrative) do not speak to each other.
Survey data is obtained by interviewing a representative sample of households in the communities about their child’s immunization status. The main ones are the National Demographic Health Survey (NDHS) or the National Immunization Coverage Survey (NICS) conducted every 4 to 5 years. Survey data is richer in details and considered the gold standard. Administrative data on the other hand is based on clinic and health facility records of children who are vaccinated in fixed or outreach posts; it is collated monthly. It is therefore more available to support program management.
Unfortunately, there is usually wide disagreement between the administrative and survey coverage estimates, with the administrative always higher than the survey for comparable years. For example, national coverage with the third dose of the pentavalent vaccine in the 2013 NDHS survey was 38% but 58% by administrative data. Put another way, survey says we reached nearly 4 in 10 kids while administrative says we reached nearly 6 in 10 kids. Which data is accurate?
Diving deeper in the NDHS 2013 raises concerns about retention in care and equity of coverage. For example, while 51% of Nigerian children get their first dose of pentavalent, only 38% end up receiving all three recommended doses, reflecting an absolute drop out rate of 25%. Furthermore, only a quarter of one-year olds received all required vaccines, while as many as 1 in 5 received no vaccines at all.
Looking the beyond the national average reveals staggering disparities by geography, residence, mother’s education and wealth quintiles. According to the NDHS, a child in the north western state of Sokoto is 32 times less likely to be vaccinated than his peer in the south eastern state of Imo. A child living in a rural area is 2.5 times less likely to be vaccinated than her mate in the city. If a child is born of a mother with no education, that child is 7 times less likely to be vaccinated than another child whose mother has secondary school education or more. Children from the poorest fifth of the wealth ladder are 11 times less likely to be vaccinated than their peers from the richest fifth.
Sobering statistics indeed. As I cradled adorable twins Hassan and Husiana in my arms during my visit to Damangaza, I knew the odds were stacked against them in terms of access to vaccination. Their mother had no education, she was in the lowest rung of the wealth ladder and they live in an urban slum. But then again, it struck me that their disadvantage can be overcome if we are intentional about finding and vaccinating children like them wherever they may be. But we will need good and timely data to do that. If administrative data over estimates coverage, we will have a false sense of accomplishment and still miss many children. If survey data is accurate but comes only twice in a decade, it is too infrequent to help us manage the program. We must find an alternative.
Dr. Chizoba Wonodi is the Nigeria Country Program Lead at IVAC.
As the global community works on ways to improve immunization data, I see a third way. This is to empower communities to generate and use their own data to track births and children’s immunization status. Through IVAC’s work on accountability for routine immunization in Nigeria, I have seen that it is possible use community structures like religious and traditional leaders or Ward and Village Development Committees to count how many children are born in the community every month. If health workers have an accurate number of births in their catchment area, the true target population, it is easy for them to measure how well they are doing with vaccinating kids.
Community structures can also be used to track dropouts or left-outs, tracing them right down to the compound and household where the children live. Such real time information will not only help the health worker do their job better, it will also give community leaders a sense of ownership of the immunization program. I look forward to the day when a village chief can tell his community’s target population and vaccination coverage; that day will bring us many steps closer to bridging the immunization gap. Data is not just for experts and nerds; it is for all of us.
Dr. Chizoba Wonodi is the Nigeria Country Program Lead at IVAC.
This post is part of the #ProtectingKids story roundup. Read all the stories here.
Lakki Marwat, Khyber Pakhtunkhwa, Pakistan
From birth to 15 months, 6 visits to the Immunization Center your child will be protected from 9 vaccine preventable diseases. Repeat after me and memorize these numbers as you did your tables in school.
As some 20 heads nod in agreement, I realized many women and girls sitting in this veranda may never have gone to school. This was an awareness session with community women of Lakki Marwat. The district in Pakistan's northwestern province of Khyber Pakhtunkhwa has a dismally low immunization coverage.
Although it was an all women session, many women had not taken off their burqa (the one which are more popularly known as the shuttlecock burqa which covers them head to toe with just a net near the face to let them see and perhaps breathe a little) for fear that a male glance may fall on them.
Although, I had heard a lot about Lakki Marwat, this was my first visit ever to the place. Khyber Pakhtunkhwa is a conservative province, but Lakki Marwat is by far the most conservative of all the districts.
I was conducting an awareness session with the community women in Lakki. I wanted to speak to young mothers and even mothers in law and tell them the value of vaccination, how it can save their children from diseases and, best of all, it cost them nothing for that. I was also very curious to find out, despite all the benefits, what prevented them from getting their children vaccinated and what could be done to improve the coverage.
I was amazed at the level of excitement and interest. They were all ears, listening in rapt silence. Giving me utmost respect and importance, they raised their hands and patiently awaited their turn if they had a query.
Pakistan is a large country with high child mortality and low immunization coverage. More than 1,000 children under five die each day. Just over half of Pakistani children are fully vaccinated against all nine diseases included in the EPI, with tremendous variation between provinces (Source: 2012-2013 PDHS). It is an important country in the immunization world, and among the last two still fighting the polio virus.
There are severe provincial disparities and marked variations in immunization coverage in provinces and districts, and by gender. A survey conducted to analyze the causes and barriers of routine immunization in three districts of Khyber Pakhtunkhwa (which included Lakki Marwat) by Japan International Cooperation Agency (JICA) late last year indicated an unfortunate 78 percent illiteracy rate amongst women in Lakki district. Knowledge of mothers that children require immunization six times was only 12 percent.
In a comparison on gender differences of children (12-23 months) who had missed routine immunization, that of girls in that area turned out to be 64 percent as compared to boys.
There are several demand and supply side challenges for this low and fragmented progress. Public awareness of benefits is low and local authorities don’t view immunization as a priority. The gap in immunization knowledge among the community impedes them from actively seeking immunization services.
But despite systemic weaknesses, the province is taking impressive steps to not only improve but improve equitable immunization coverage. Lakki Marwat will be amongst the three priority districts in which the provincial government will be working on social mobilization in 2016.
One thing was evident – this was not a place frequented by visitors from other towns, let alone women. I recalled when, during our discussion, the Khyber Pakhtunkhwa EPI Program Manager had, in a sort of challenging cum daring tone, suggested Lakki for the advocacy session with community, if I was really serious in doing a meaningful session. However, while confirming the date and venue, the District EPI Coordinator of Lakki had clearly said I should return home by evening alluding to the place not being safe for women to stay the night.
Knowingly leaving this last piece of information from any conversation I had with my family on my impending visit to Lakki, I did, however, return the same night travelling a good 13 hours on the road. In retrospect, it was one journey I found to be far more satisfying than many others I have taken in my quest to spread the knowledge about the value of vaccinating children against childhood diseases.
Huma Khawar is an IVAC consultant who works on immunization advocacy with stakeholders on the ground in Pakistan.
This article was originally published in Open Magazine and is cross-posted here with permission.
This post is part of the #ProtectingKids blog series. Read the whole series here.
Niya Zameen with her two boys outside their home in Ramsar
Niya Zameen, 33, lives with her two sons in Ramsar, in Barmer district of Rajasthan. Her village has a population of just 1,078 and is close to the India-Pakistan border. Niya has always tried to ensure that her children receive the necessary healthcare services, including vaccines, to give them a healthy start in life. Getting her children vaccinated hasn’t always been easy because of shortages of government recommended vaccines. But Niya has never given up. With the help of the local health worker, Rampatti, she made sure that her children received the necessary vaccines against measles, polio, and three doses of diphtheria-tetanus-pertussis.
Of the 1.3 million Indian children under-5 that died in 2013, pneumonia claimed more than 175,000 lives and diarrhoea caused more than 130,000 deaths. Even in cases of survival, the severe burden of illness from diarrhoea and pneumonia adversely impacts children’s growth and development. But many of these severe illnesses can be easily prevented through immunisation. The pentavalent vaccine, that prevents a deadly form of pneumonia and meningitis, is now available through government immunisation programmes in some states and the vaccine to tackle diarrhoea caused by rotavirus, will soon be rolled out.
Niya Zameen acknowledges the crucial role that Rampatti, the local health worker, plays in her life. She has provided guidance on important health decisions, including the role of vaccines in giving all children protection against preventable diseases.
Vaccine delivery is a challenge in this region, due to extremely hot weather and the difficult desert terrain. If the vaccines don’t arrive on the designated day of immunisation, Rampatti travels to the vaccine cold chain point to collect them for her village. On her return, she vaccinates children.
Every child has the right to a healthy start, and it is the responsibility of not just the government, but also of the community to ensure that all our children are timely and fully immunised.
Photos by Shikha Nayyar