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Johns Hopkins Bloomberg School of Public Health


Keyword: vaccines

By Dr. Kate O’Brien, Executive Director, International Vaccine Access Center (IVAC)

Yesterday we were saddened to learn that former President George H.W. Bush was hospitalized with pneumonia. While the majority of people affected by pneumonia in the US are adults, around the world each day this condition claims the lives of an estimated 2,500 children under age 5. 

Back in September, when Secretary Hillary Clinton suspended her campaign due to pneumonia, I wrote about the under-recognized toll this illness takes on communities around the world. As we find ourselves on the eve of a new presidential administration, it’s imperative to repeat the message and remind policymakers of the common needs of families around the world.

Pneumonia, an infection of the lungs, is exceedingly common around the world, with an estimated 450 million cases annually. In the US, we have ready access to trained physicians with the know-how and equipment to make a diagnosis and, when necessary, we have antibiotics and oxygen therapy to treat illness. These interventions have been proven effective, and the vast majority of people who contract pneumonia in the US make a full recovery.

Sadly, this is not true everywhere. In impoverished countries, timely, appropriate, and affordable treatment is often not available, especially for young children whose course of illness can take a downturn very quickly. In parts of Africa and Asia resources are scarce, and HIV infections, crowding, and indoor air pollution are prevalent and put people at risk. The prevention measures we take for granted, such as vaccines and hand washing, are too often not available. The price of pneumonia in these countries is higher infection rates, more illness and, sadly, more deaths, especially in children younger than 5 years of age.

Over the past 15 years, public health professionals and policymakers have been able to assure significant progress. Vaccines to prevent the deadliest causes of pneumonia are rapidly being deployed in countries in most need—thanks to Gavi, the Vaccine Alliance, and country governments. Gavi, to which the US government is a major contributor, makes it possible for low-income countries to buy and deploy tens of millions of doses of life-saving vaccines, including against pneumonia, to millions of children. As more children have access to vaccines and medicine to prevent and treat pneumonia, we see less disease, fewer lives lost, more families climbing out of poverty and fewer families thrown back into the downward cycle of poverty which is otherwise incurred simply by trying to get medical care to save their child’s life.

Yet, much work remains. More than 900,000 young children still lose their lives to pneumonia each year. These children need access to the same tools as our own children to prevent, diagnose, and treat this common illness.

More than anything else, we must put pneumonia on our collective radar as a global health problem that requires attention—not just when there’s a new media headline. How many people know that globally pneumonia is the leading cause of death for children under 5 years of age? Pneumonia is so common that it’s nearly invisible.

Can this change? Absolutely. We have the opportunity to raise the profile of this illness and reveal just how pervasive it is. We hope President Bush makes a speedy and full recovery. Meanwhile we continue to advocate for adequate resources for families, governments, and communities everywhere to prevent and treat this illness. What improves the lives of people in countries around the world is also good for the US. It’s simple: Hopeful, healthy communities create a world where we all thrive, including here at home. 


Kate O’Brien, MD, MPH, is the Executive Director of the International Vaccine Access Center and Professor at the Johns Hopkins Bloomberg School of Public Health. She is a pediatric infectious disease physician, epidemiologist and vaccinologist.

In celebration of World Immunization Week, we asked some of our staff to reflect on their careers and why immunization is a critical tool in public health.


Here’s what inspires them:

What was the moment you realized you wanted to work in the immunization/vaccines field?
“It clicked for me when I was taking care of kids who had Hib meningitis during the late 1980's right after the vaccine was starting to be used in the United States.” – Kate O’Brien, Executive Director

“While serving as a Peace Corps Volunteer in West Africa, I worked with the local Ministry of Health's National Immunization Days for Polio.  I spent a week traveling out to remote villages vaccinating children and providing Vitamin A supplements to prevent Polio.” – Matt Coles, Senior Program & Contract Analyst

“After completing my pediatric training I worked in Addis Ababa, Ethiopia as a pediatrician for two years and saw many children die of vaccine-preventable diseases, most notably measles and meningitis.” – Bill Moss, Deputy Director

What do you find rewarding about working in global health? In immunization/vaccines?
"Knowing how much of an impact vaccines can have on every family.  Many families will never know the devastation of these preventable illnesses and knowing I contributed to that, even in a small way is HUGE for me.” – Lois Privor-Dumm, Director of Policy, Advocacy & Communications

“Being a positive part of a global community.” – Diane Coraggio, Research Associate

“Working in global health has allowed me to understand the root causes of poverty and disease that plague the majority of the world, and do so inequitably, and has provided me with the confidence and skills I need to contribute to changing the current situation and addressing those root causes.” – Olivia Cohen, Research Associate

“Immunization programs target healthy people and aim to keep them healthy. What better way contribute to public health?” – Kyla Hayford, Research Associate

What are you most proud of in your work at IVAC or in immunization/vaccines?
“I am always proud when the pediatricians and public health experts we have worked with advocate for change and speak up for needed interventions in effective ways - I love seeing a little bit of training and empowerment turn into something much bigger and better than we would have ever thought of!” – Lois Privor-Dumm, Director of Policy, Advocacy & Communications.

“I'm most proud of the impact our work has----it has tangibly and meaningfully contributed to actually moving the needle on getting vaccines to the people and places where they are most needed.” – Kate O’Brien, Executive Director

“It's especially rewarding when governments and policymakers use our work to make decisions around vaccines. “– Brian Wahl, PhD Candidate

What is something about immunization/vaccines that you wish more people knew?          
“Vaccines are by far one of the most cost-effective public health solutions!” – Diane Coraggio, Research Associate

“Immunizations are the best buy out there-----there isn't anything that does a better job of preserving health and enhancing life.” – Kate O’Brien, Executive Director

What do you find most challenging about your vaccine/immunization work?         
“There is so much to do and so little time!  The vaccine world is a complex space and this field needs the best, the brightest, and all of our efforts to make accelerated progress.” – Kate O’Brien, Executive Director 

“One of the most challenging things about successful vaccine work is that it can undermine itself. The disease goes away and people no longer understand how important vaccines are and they played in reducing the disease burden.” – Bill Moss, Deputy Director

What do think is the biggest challenge to closing the immunization gap? 
“I think the focus needs to be more on the hard to reach with an understanding that where the greatest burden is (often where health systems are weakest) is truly the priority.  There have been some examples of successful programs, countries, communities and the global health community need to focus on all aspects of strengthening immunization programs - both on the demand and supply side.” – Lois Privor-Dumm, Director of Policy, Advocacy & Communications.

“Delivery, delivery, delivery and optimizing the ways in which we use the vaccines we have.” – Kate O’Brien, Executive Director 

“Reaching populations in areas of continuous conflict zones, refugee camps, and increasingly in areas of recent natural disasters.” – Olivia Cohen, Research Associate

“Improving accountability and governance in many developing countries and integrating immunization with other primary healthcare services will help close the gap.” – Brian Wahl, PhD Candidate

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.

Chizoba Wonodi
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.

By Rose Weeks

This article was originally published on Next Billion and is cross-posted here with permission. 


When my 6-week-old son got his first rotavirus vaccine dose last year, my husband and I were up what seemed like all night as he fussed and spat up. But even in my sleep-deprived state, I felt relieved to know that he would be protected from this life-threatening diarrheal disease.

Before the rotavirus vaccine was introduced in 2006, hundreds of children died from diarrheal disease in the United States. It was a devastating and preventable loss of life, but a tiny fraction of the 600,000 children estimated to die globally from diarrheal disease annually.

The just-published Pneumonia & Diarrhea Progress Report states that countries with the largest number of deaths from these diseases have not yet fully scaled up the use of available solutions to prevent and treat diarrhea, like rotavirus vaccine, oral rehydration solution (ORS) and breastfeeding.

Diarrhea still kills 1,000 per day: “It’s better, but it’s still horrific,” said Dr. Richard Guerrant, the director of the University of Virginia’s Center for Global Health, at last month’s annual meeting of the American Society of Tropical Medicine & Hygiene, a convening of thousands of public health scientists.

Beyond the death toll, incidence has barely waned at all. Children in low- and middle-income countries continue to experience about three episodes of diarrhea each year. Repeated cases of severe diarrhea, especially during important development stages in a child’s life, can have a lasting impact on physical and cognitive growth. Diarrhea can also make children more susceptible to death from other causes like pneumonia.


ORS only reaches 1 of 3 children in need.
Children sick with severe diarrhea can be fully rehydrated with ORS – an inexpensive mixture of sugar, salt and safe water – within a few hours. ORS has saved an estimated 50 million lives worldwide. However, only one-third of children in low- and middle-income countries who need ORS get it.

Dr. Christopher Duggan, a professor in the Harvard School of Public Health who has studied ORS since the 1980s, spoke at the TropMed annual meeting about how social marketing is a critical tool to expand access. In Bangladesh, Social Marketing Company, an offshoot of PSI, has invested millions in marketing the use of ORS. Today, Bangladesh’s coverage for ORS is 77 percent, the best of the high-burden countries. Bangladesh also packages zinc supplements – another proven way to reduce the duration and severity of diarrheal episodes – with ORS. As a result, the country has attained higher coverage of zinc use than any other country surveyed.

Even when not fatal, diarrheal infections stunt children’s growth and cognitive development.
Malnutrition weakens immune systems, making children more vulnerable to infections like diarrhea. Diarrhea, in turn, prevents children from absorbing nutrients, contributing to malnutrition. This creates a viscous cycle. Children with a typical number of diarrhea cases per year suffer an average of 8-centimeter growth loss and a 10-point IQ loss, said Guerrant.

Making the situation worse, many caregivers withhold food from children and babies when they are suffering from diarrhea. It is very important to continue feeding children appropriate food during an episode of diarrhea, said Duggan.

Innovative market-based approaches to improving nutrition include mobile clinics, training community health workers and door-to-door sales of Sprinkles (sachets containing micronutrients). Some m-health programs like Totohealth in Kenya use SMS to monitor child development.

Vaccines against rotavirus, which causes 2 in 5 diarrheal deaths, are not reaching more than 90 million children or 70 percent of all infants worldwide. And not all children in the U.S. are vaccinated.
Rotavirus causes 40 percent of diarrhea hospitalizations and 200,000 deaths in children younger than 5 each year. Unlike other forms of diarrhea, rotavirus infections cannot be controlled by hygiene and sanitation alone.

Two rotavirus vaccines have been internationally licensed since 2006 and are used routinely in nearly 80 countries. Despite this, only 15 percent of the children in countries eligible for vaccine support from Gavi, the Vaccine Alliance – the world’s poorest – have access to rotavirus vaccines.

Dr. Umesh Parashar, who leads the Centers for Disease Control and Prevention’s Enteric Viruses Epidemiology Team, said that the use of rotavirus vaccines in the U.S. has led to a striking decline in rotavirus-related hospitalizations. In some years, there are few cases observed. Yet, because coverage is still not routinely high, varying geographically from 59-88 percent, the accumulation of unvaccinated infants periodically leads to outbreaks.

Public health impact has been dramatic in low- and middle-income countries where rotavirus vaccines have been introduced. In Mexico, the vaccine led to a 50 percent decrease in diarrheal deaths in children younger than 5.

New rotavirus vaccines are being developed in emerging economies to expand supply and lower price, but may need more help to be available for other countries.
Dr. Duncan Steele of the Bill & Melinda Gates Foundation – now making headline-worthy investments in accelerating the introduction of rotavirus vaccine in low- and middle-income countries – discussed one bright spot on the horizon.

Companies in China, India, Indonesia and Vietnam are developing new vaccines with prices as low as U.S. $1 per dose for governments (such as Bharat Biotech’s ROTAVAC, which India is soon rolling out in four states). But there are not yet enough doses of these new vaccines to cover all children in the countries where they are being produced, much less the millions of children around the world who are in need of this vaccine.


“The main message is – we are not winning this fight,” Steele summarized, pointing to the need for greater advocacy to mobilize support for proven, low-cost diarrheal disease solutions such as ORS, zinc and dysentery treatment.

“The time to act is now,” urged Mathu Santosham, chair for the Rotavirus Organization of Technical Allies Council.

Fourteen of the 15 countries with the most deaths due to pneumonia and diarrhea are currently eligible for new vaccine support from Gavi, but five won’t be eligible for long and some have only months to seek funding for rotavirus vaccines. Most poor countries have yet to approach global targets for ORS and zinc use.

Regardless of their birthplace, all children should be protected from suffering, stunting and the risk of death from diarrheal disease.

Rose Weeks is the director of communications for the Center for American Indian Health at Johns Hopkins Bloomberg School of Public Health and secunded to the International Vaccine Access Center to support the ROTA Council project.