The Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD) was launched last month. Now this week we’ve learned that a new rotavirus vaccine from India, Bharat Biotech‘s ROTAVAC, looks promising, and The Lancet featured results from the Global Enteric Multi-Center Study or GEMS, which offers a comprehensive look at the causes of diarrhea in children, such as rotavirus. In light of this recent news and its impact on efforts to prevent and treat diarrheal disease, especially rotavirus, we sat down with Mathu Santosham, MD, MPH. Dr. Santosham co-chairs the ROTA Council and also chaired the Data Safety and Monitoring Board for the ROTAVAC trial established to protect the participating infants’ rights and needs during the trial.
Why is all of this recent news important for children?
Mathu Santosham, MD, MPH
We know that pneumonia and diarrhea are the leading killers of children under 5 worldwide, and we know that we need an integrated approach that uses all proven tools to tackle these two illnesses and prevent unnecessary suffering and death. GAPPD is important because it provides a framework, designed to inform global and national programs and policies, for integrating efforts against these two child killers. It sets ambitious but achievable goals including reducing under-five pneumonia and diarrhea deaths to 3 per 1,000 live births and 1 per 1,000 live births, respectively. A big part of the strategy for tackling both illnesses is vaccination.
For diarrhea, we know rotavirus – a pathogen for which there is a vaccine – is the leading cause of severe diarrhea among infants and children. In fact, the active surveillance results announced from the seven sites in GEMS reaffirmed this understanding, and offered important insights that will help better target interventions to the pathogens like rotavirus that are causing the most diarrhea. We also know that rotavirus contributes significantly to child mortality. According to the most recent estimates, more than 450,000 children died from rotavirus diarrhea in 2008. Rotavirus vaccine is critical to protecting children from rotavirus and preventing illness and death.
There are currently two licensed rotavirus vaccines, and they are saving lives and improving health today in the countries where they are in use. Having an additional vaccine from an Indian manufacturer will expand the market, which will offer more options to protect children in India and around the world. If licensed, Bharat has committed to offering the initial frozen formulation at $1 per dose, which will increase market competition for countries and organizations procuring vaccine. Also, it is especially encouraging to see India making so much progress toward a vaccine because nearly one-quarter of rotavirus deaths occur in India.
Why is rotavirus such a large concern?
Rotavirus is highly contagious and can last for long periods of times on hands and surfaces. It is not adequately prevented by proper hygiene or improvements in water and sanitation, like other pathogens that cause diarrhea. So even children in developed countries are susceptible to contracting rotavirus. In fact, nearly every child will be infected at least once by the age of 5. Once infected, a child often experiences symptoms that include fever, vomiting, and diarrhea. In developed countries where access to care is more reliable, children are unlikely to die from this infection, but in developing countries, children are less likely to have quick access to oral rehydration, making them at risk to suffer severe dehydration. This can lead to hospitalization and even death. In addition, children who suffer from malnutrition are more vulnerable to diarrhea, and diarrhea in turn worsens their malnutrition, resulting in a vicious cycle. For these reasons, rotavirus is a concern worldwide, but especially in developing countries.
What can we do about rotavirus?
Rotavirus cannot be treated with antibiotics or other drugs. However, its symptoms can be alleviated by prompt use of oral rehydration therapy (ORT), which includes home available fluids, oral rehydration salts (ORS), and, in cases of severe dehydration, IV fluids. ORT can effectively treat most rotavirus infections, but when the treatment is received too late, rotavirus can be deadly. In India, only about 4 in 10 children receive ORT when they have diarrhea. Vaccination, on the other hand, can actually prevent rotavirus diarrhea from happening in the first place. The two currently licensed vaccines, Rotarix and RotaTeq, have been demonstrated to be safe and effective and have been introduced in more than 45 countries. When combined with ORT, zinc supplementation, breastfeeding, and improvements in nutrition, hygiene, and water quality, vaccines contribute to the comprehensive approach required to effectively prevent severe illness and deaths caused by rotavirus diarrhea.
What is ROTA Council doing about this problem?
Dr. Santosham with other members of the ROTA Council at the International Rotavirus Symposium in Bangkok, September 2012.
The ROTA Council, which I co-chair with Dr. Ciro de Quadros of Sabin Vaccine Institute, is a dedicated team of technical experts with the mission of saving children’s lives by accelerating the introduction of rotavirus vaccines. We work at the global and country level to ensure that policy makers have the latest evidence-based information to inform their decisions about introducing and scaling up rotavirus vaccines as part of broader diarrhea control efforts. At the same time, many of our Council members are on the frontlines of research, conducting the studies needed to demonstrate vaccine efficacy, safety, and impact. We are pleased to see that more than 45 countries have introduced rotavirus vaccines, but many more are still leaving their children unprotected, particularly in Asia, where countries have been slow to introduce the vaccine.
Why should India and other low- and middle-income countries introduce rotavirus vaccine?
Rotavirus diarrhea is a ubiquitous problem that can have some very serious consequences. In India, and other countries where access to care can be quite unequal, prevention becomes even more critical. If left untreated, rotavirus infection can lead to unnecessary illness, hospitalization, and even death, which is not only concerning from a health standpoint, but also takes a very serious toll from a social and economic standpoint. Hospitalization for one child with rotavirus costs nearly the entire amount of an average Indian household’s spending in a month. Diarrhea related healthcare needs are also costly for the country and stretch its already burdened state healthcare system. Beyond direct costs, vaccination could avoid productivity losses and help children grow into healthy, educated, productive adults.
The vaccine has the potential to make a big difference in the lives of families around the developing world. In India alone, we could prevent tens of thousands of deaths, not to mention nearly 300,000 hospitalizations and more than 300,000 doctor visits, which amounts to savings of over US$20 million in medical costs.
Based on your experiences, what is your hope for India and the rotavirus vaccination?
As a medical student in India in the 60s I saw children dying of diarrhea every day. Over the years, we were fortunate enough to develop powerful treatments like ORT, which helped to reduce the number of diarrheal deaths per year from 5 million in 1980 to less than a million now. However, more than 700,000 children continue to die from diarrhea annually because they don’t get the necessary treatment on time. Rotavirus is the leading cause of these diarrheal deaths, and it is a tragedy to see a child die from rotavirus when we have such a powerful weapon to combat this disease. It is my sincere hope that every child in India will soon have access to this life-saving vaccine.
Mathuram Santosham, MD, MPH, is Co-Chair of the ROTA Council and Professor of Pediatrics and International Health at Johns Hopkins University. He also serves as Director of the Center for American Indian Health, Director of the International Center for Maternal and Neonatal Health, and a Senior Advisor at IVAC.
This is the first in a series of profiles to help IVAC partners and friends get to know our team. We thought we’d start with Lois Privor-Dumm, a long-time IVAC team member and Director of our Alliances and Information team. We caught up with Lois in between her busy travel schedule to chat about her background, her work at IVAC and what she likes to do in her spare time.
Tell us a bit about your background, what inspired you to work in global health, and how you ended up at IVAC.
I didn’t set out to work in global health, but I’ve always wanted to work internationally. I spent most of my career in the private sector and was fortunate enough to have the opportunity to launch Prevnar®, the first pneumococcal conjugate vaccine (PCV), in the U.S. and then help other countries around the world introduce the vaccine. I had worked with other vaccines and pharmaceuticals, but this experience, coming in direct contact with families impacted by pneumococcal disease, particularly meningitis, made a major impression. I saw the value that the vaccine had for countries that had introduced, but also recognized the severe disparities that existed in vaccine access around the world. I decided I could play a role in helping reduce those disparities. Although I was able to influence some change while working in pharma, I thought I could make a bigger impact by bringing my understanding of the industry and my marketing and operations experience to public health. I was fortunate to be working with experts on PCV, including Orin Levine, Mathu Santosham and Kate O’Brien, who recognized how my perspective – despite my non-traditional background for a public health career – could be beneficial. We shared the vision that new vaccine introductions did not need to see delays of 20 years or more between licensure and introduction in low-income countries, and helping devise and implement a plan to achieve this goal was very intriguing to me.
So, I first joined Hopkins in 2005 as Director of Communications and Strategy on the Hib Initiative and soon after took on the role of Director of Access and Implementation, and later Communications, for the PneumoADIP. Our approach of addressing the needs of all stakeholders – countries, donors and suppliers – proved to be an effective way to achieve our vision, and we’ve been fortunate that we’ve been able to continue our mission through what is now IVAC. I consider myself very lucky to work with such a diverse, creative and talented team. I think it is the team and the way we work that has enabled us to work on some really tough challenges that have a big impact and achieve success.
I’m also a strong believer that there are always solutions and, at Hopkins, I value the opportunity to help facilitate those solutions, bringing both a manufacturer perspective and that of someone working with global health colleagues and country leaders. There’s been significant progress in vaccine access in the past decade or so, and I hope our work will continue to accelerate greater access and equity for vaccines and other interventions that make such a difference in peoples’ lives and contribute to healthier and more productive societies.
What projects do you work on at IVAC?
Lois Privor-Dumm and a group of children at the 1st National Vaccine Summit in Abuja, Nigeria in April 2012.
I lead the Alliances and Information team at IVAC, which includes projects covering advocacy and communications – both globally and in-country – as well as policy research and supply and access issues. I spend a great deal of time on our country-focused work, namely India, where we have been working to synthesize the evidence base and advocate for interventions for pneumonia and diarrhea at both the national and state level, and Nigeria, where we have helped analyze barriers and solutions to improve routine immunization and continue to provide technical support and encourage government accountability. I’m also excited that we’ve recently added country work with Pakistan.
Our work is varied, and there is never a dull moment. Our efforts have helped others become advocates and add their voice to important issues in child health. For instance, we’ve run advocacy workshops and collaborated with a network of trained experts to address child pneumonia and diarrhea in their countries. We support the efforts of experts including the ROTA Council, a dedicated council of scientific experts working to accelerate the introduction of rotavirus vaccines, and the Global Coalition Against Child Pneumonia. With the help of key partners, we established World Pneumonia Day to call for action on protection, prevention and treatment of the leading global killer of children. Our team also coordinates closely with IVAC’s Epidemiology and Economics & Finance teams to help communicate the results of their work and highlight the work of other researchers that relates to vaccines and child health.
Last but not least, I spend much of my time on our supply and access work, which is also very important. One of our more recent projects centers around primary container decision making and building awareness of how these seemingly straightforward decisions have significant impact on not only cold-chain space and procurement cost, but also wastage and other costs, vaccine coverage, and safety. We’ve developed a framework and have been working with various experts to help advocate for a more robust approach to considering all the implications of these decisions.
I’d be remiss not to mention, that none of this, of course, could be done without the great team of hard working and very capable individuals and students on the A&I team.
What have been some of your most rewarding or memorable experiences at IVAC?
One of my most memorable experiences was my first week at Johns Hopkins. I was working with the Hib Initiative and went to the Gambia and Bangladesh to film the BBC World Kill or Cure: Hib documentary, which highlighted the impact of the disease and efforts needed to bring a vaccine to developing countries. I remember meeting people at the labs and families that had been affected by meningitis and seeing how dedicated they were to finding the solution. I have great memories from that trip, for example touring the lab at MRC and then having tea with a family in the Gambia with little kids around very curious about all of our cameras. Bangladesh was no different, although it was tough seeing a child and her mother who did not know whether her daughter would survive the night or succumb to a severe case of pneumonia.
Another big moment was the first World Pneumonia Day in 2009 and seeing that kick off not only in the U.S. but probably more importantly around the world. That sense of pride continues when I see how many other people have taken up the cause. As we move into World Pneumonia Day’s fifth year, I am increasingly impressed by the level and volume of activities that take place – creating a global community of sorts. The fact that people are talking about antibiotic access, bringing new vaccines into countries, improving breastfeeding rates – it is very gratifying.
What is the most interesting place you’ve traveled to? Anyone who has seen your passport will know this will be a tough question to answer.
Yes, it is. Everywhere I’ve gone has been interesting. Large countries hold a lot of interest for me simply because of the level of contrast you see within the same country. I’m always struck by the disparities within the countries, but at the same time, the level of hope and generosity of those that don’t have much. I am fascinated by the diverse modes of transportation like the trucks that are brightly painted with “honk please” signs in India and Bangladesh, navigating the same roads as people walking with bundles of firewood on their heads or families piled three or four onto a small motorbike seat. In Nigeria I’ve been captivated by the people and the diversity of just about every aspect from dress to food, language and density of the population. And in some countries you’ve got such a long history that can’t help but impact you – Angkor Watt in Cambodia, Petra in Jordan, and slave quarters in Africa – it reminds me of how far the countries have come, yet how much more is still to be achieved.
Since you spend a lot of time in India and Nigeria, what similarities and differences do you see between the two?
Lois Privor-Dumm and fellow participants at a national course on pneumonia and diarrhea prevention in Delhi in December 2012.
That’s a great question. I’d love to hear the perspective from those who live in one of the two countries. From my perspective though, they are similar in that they both have some wonderful, high caliber people. Both have large bureaucracies and complex environments, and I’m always impressed by
individuals who’ve been great champions of children who’ve successfully been able to navigate the environment and overcome some real barriers to getting things done. The real heroes are the ones who’ve been able to not just talk about change, but have been able to see things through, and there have been examples in both places. Another similarity is that health is very much a state subject, and implementation and sustainable change is highly dependent on the individual states. As different as priorities and ways of life are between these countries, the same can be said of individual states, and it is important to understand the priorities and players in each.
Both countries obviously have had to tackle an ongoing challenge of polio, and the related challenges and opportunities of an enormous vaccine effort. India has now gotten ahead of the curve with no cases of wild-type polio for the past two years. Nigeria still faces many challenges with polio, but has moved ahead to strengthen routine immunization and add new vaccines.
One major difference may be in the way vaccines are portrayed in the press in each country. Although the dialogue is changing and more and more positive stories emerge surrounding vaccines, media in both countries still often like to report on sensationalist stories that do not hold scientific muster, and controversy reigns. Politicians and bureaucrats often do not recognize how political capital can be built by improving routine immunization. In Nigeria, although there are anti-vaccine sentiments, particularly surrounding polio in certain areas, health is an important issue, and leaders will take advantage of reporting on the steps they’ve taken to combat disease.
On a related note, what progress have you seen in vaccine access in India and Nigeria recently, and what do you expect to see in the next few years?
I think there is much more recognition in both countries that the systems must be strengthened, infrastructure for delivering polio immunization can be leveraged, and that a focus on bringing up routine immunization coverage will benefit new vaccines and vice versa. There has been a greater level of engagement at the state level, and I expect that this will become increasingly important moving forward. As states are implementers and must ultimately ensure that there is both adequate demand and supply, their engagement in the planning and decision-making process is key. Another area that should see improvement over the next few years is surveillance, not only to be able to measure the impact of the vaccines but also to be able to monitor any adverse events that may happen and to quickly determine if they are related to the vaccine. This has especially been a challenge in India, where activists and media have questioned whether adverse events are due to vaccine and have treated government assurances with suspicion. Good surveillance with baseline measures of child health statistics prior to introduction will make it easier to assess claims and address concerns that may be unfounded, as well as provide a basis for measuring the trends and impact that are so important to communicate to sustain public and policy maker support for vaccines.
On a personal note, when not traveling internationally, you split your time between Baltimore and West Chester. What do you like about each?
Yes, both places are great. West Chester is where I’ve lived for a long time, and where I spend a part of the week with my husband and dog. It is a historic city with brick sidewalks, and a small town where I’ve gotten to know a lot of people over the years. I consider it home, although I am originally from upstate NY. Baltimore is a great city. I love where I live in Fells Point, right by the water. I’ve got great colleagues and friends in the city, and the ability to walk to work is a huge bonus!
Do you have any interesting hobbies?
I like doing things outside, including spending time gardening, hiking and exploring different places old and new. But, there is no place I’d rather be than under the water diving (although on safari is a close second). I’ve been diving since 1992 and try to go every year. One of my favorite places is the South Pacific where you have just an amazing range of color and variety of marine life – sharks and eels and all sorts of different things. I think I like it because I’m an explorer at heart, and you never know what you’re going to find down there, and it’s a way to really relax.
What is the most recent book you’ve read?
I just read Cutting for Stone about a doctor from Ethiopia and am now reading Behind the Beautiful Forevers – Life, Death and Hope in a Mumbai Undercity. I like reading about places I’ve been or would like to go. I also have been reading some of the excerpts from an international thriller novel a friend of mine is working on publishing – can’t wait to see that in print.
Ok, just one last question. If you could have dinner with anyone, alive or dead, who would you pick and why?
That is a really tough question. Can I just throw a party?! I’d love to meet famous women who have made a difference – like Aung San Suu Kyi or, closer to home, Hillary Clinton. They are role models for how you can help change the world. And then there are people who I’m just starting to hear about who are doing some cool things with social innovation – not as well known of course, but just as inspirational. Coming from a business background, I’m interested in hearing about new ways to solve the world’s problems.
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.
Next month, Dr. Orin Levine will leave his post as Executive Director of IVAC at Johns Hopkins Bloomberg School of Public Health to join the Bill & Melinda Gates Foundation as Director for Vaccine Delivery in the Global Development Program. Before he leaves, we asked him to reflect on the last 10 years and the changes he has seen in vaccine access and in the organization he helped build.
You started at Johns Hopkins with a single vaccine access project, GAVI’s PneumoADIP. Today, IVAC is a leader in vaccine access research and practice, with projects tackling a wide range of vaccine-preventable diseases across a mix of disciplines. What were your goals for the organization, and did you imagine it becoming anything like what it is today?
When we started PneumoADIP (Pneumococcal Vaccine Accelerated Development and Introduction Plan) we had no idea it would grow so quickly and evolve into what is now IVAC. And I know that because, when I took the job my wife and I had just had our first daughter and I told her, ‘don’t worry it’s just a three year grant, $30 million, a small team of about seven or eight people.’ Now, almost 10 years later, with a team of more than 30 people and the scope and breadth of what we are doing – it was almost unimaginable when we got started.
PneumoADIP was a really remarkable opportunity. One of the things the PneumoADIP team was really focused on was that this was the best chance we had ever had at making a really big difference on accelerating vaccine access. We were very focused on moving the needle, on getting pneumococcal vaccines out faster and more widely than ever before. So that team, that purpose, that mission, really came together all at once in a very special way.
Tell us about the evolution from PneumoADIP to IVAC.
Dr. Orin Levine speaking at the launch of the UK All-Party Parliamentary Group on pneumococcal disease prevention in 2007. (Photo Credit: Amit Lennon)
In retrospect, PneumoADIP occurred at a really exciting time in global health and global vaccine access. GAVI was new, the Bill & Melinda Gates Foundation was new, and people were asking questions about what is possible and raising their ambitions. At the same time all the architecture was also new and small. There was an incredible space for a team based at Johns Hopkins Bloomberg School of Public Health (JHSPH) to play a leading role in the effort to get new vaccines out in collaboration with GAVI and a lot of other players.
The team really embraced that. We were very focused on a handful of core strategic goals. We designed everything to be rigorous and collaborative. Those are qualities that have carried forward into IVAC. We saw a compelling injustice, that pneumococcal vaccines were being used here in the United States and not where they were needed the most. That injustice is what drove people here at IVAC – and still does – to get up and come into work and do what they do.
You often refer to the ‘summer that wasn’t’ in 2008. Can you tell us about that?
The summer of 2008 was pivotal for us at IVAC and one busy summer. At that time, it was apparent that pneumococcal vaccines were going to roll out in GAVI countries and we were ahead of any historical precedent with a new vaccine. They were poised to take off, but they weren’t yet in the countries. There was a feeling here at PneumoADIP, soon to be IVAC, that while we could take some legitimate credit for having built things to the point where the table was set for rollout, it hadn’t quite rolled out, and we were anxious that if we left the scene, for whatever reason, it wouldn't continue the way we had envisioned. So, we were in this moment where the success, the thing we had worked so hard for, was almost there but not quite. We wanted to be part of that next step - the sometimes messy process of getting to implementation.
The PnuemoADIP contract was coming to an end so we knew that to be part of the next phase we had to write a proposal. At the same time, we wanted to keep the team together not knowing what was going to happen. We were pretty busy writing proposals in the summer of 2008. We wrote two really big proposals, one for the follow on from PneumoADIP - AVI - and one for PERCH, the world’s largest pneumonia etiology case-control study in a generation.
We had this attitude that we would be happy working as a team on either grant and then we won both. That was a really big step for us. It helped us feel like we could continue on the pathway that we had started with PneumoADIP, but it also really said to us that people recognize what our team can do. From that time forward, we just continued to diversify our portfolio, building off that same core of teamwork and innovation in solving difficult problems.
So were you able to rest at all that summer? Was sleep on the agenda?
It was, but not much. As with everything at IVAC, it was a team effort pulling those proposals together but, as I always tell people, when you pack a printer for your vacation, it's a pretty bad sign the vacation won’t go how you planned. That was certainly true that summer. I remember it so well. We were packing up the car with towels and boogie boards and there was a box with a laptop and a printer in it.
What are some of the other highlights over the past 10 years?
Dr. Orin Levine in South Africa filming a documentary about pneumococcal disease for BBC in 2004. (Photo Credit: IVAC)
I'll give you a few because there were many, obviously with a team as talented as this one. One of the highlights was the very first strategic retreat of the PneumoADIP team. We got the PneumoADIP award in January of 2003 and by June, had identified, recruited and brought on campus everybody on the team. Together, with Thomas Cherian from WHO, we sat down for two days in Baltimore and built the strategic plan. Basically we mapped out the next few years of PneumoADIP on big sticky notes on the wall. It was really great to see everybody come together around this common vision and suspend disbelief for a couple days. You know it was pretty outrageous to believe in 2003 that we were going to accelerate access to the world’s most expensive vaccine for the world’s poorest countries, and yet they bought it and it has made a big impact.
The first IVAC video documentary we did was another highlight. We really put a face on pneumococcal disease, the problem and what could be done in a way that hadn’t happened before. I remember a few days after it aired on BBC World I got a phone call from a senior executive at a major vaccine manufacturer who said ‘That documentary was incredible. I watched it with my teenage kids and at the end they said to me, dad you need to get that vaccine for those kids in developing countries.’ With that I really came to appreciate the power of making the case with video and other multimedia. The case always starts with evidence, but using that kind of tool was really important.
We had a number of other highlights on the evidence side. It was a major accomplishment when our team built up pneumococcal surveillance in collaboration with WHO in more than 50 countries, then leveraged that data to generate disease burden estimates for the whole world, and then, in order to meet the needs of the $1.5 billion Advance Market Commitment, did the most incredible work on this project called the global serotype project. That's memorable because we had an incredibly tight turnaround. We got the final analysis and then had to summarize and submit back to GAVI and the AMC committee the night before it was due. I remember it was in August because it was Kate O’Brien’s birthday, and we spent her birthday as a team in her kitchen up until 3 a.m. writing that report.
So birthdays and vacations were often spent writing reports?
Definitely not, but I can see how it looks that way. [laughs] We have a team that knows how to celebrate as well as work hard and we shared many great times together. But when the team saw a $1.5 billion opportunity for pneumococcal vaccines, they made the sacrifices too.
Was there an especially memorable achievement for you over the years?
A really memorable moment was being in Rwanda for the launch of the first GAVI-supported pneumococcal vaccine program in 2009. I was there with the CEO of GAVI at the time, Julian Lob-Levyt, and seeing the expression of our work as kids getting vaccinated for the first time was a tremendously
Dr. Orin Levine speaking with a nurse in Rwanda at the launch of the first GAVI-supported pneumococcal vaccine program in 2009. (Photo Credit: Thomas Rippe)
memorable experience. We had an event in Rwanda where kids got vaccinated and then we arranged a conference call back to Baltimore with the whole PneumoADIP team. The GAVI CEO joined me for that call and thanked the team for their work over the years to make this launch possible. Even though I wasn’t in Baltimore, you could feel, even over the phone, the pride that was coming from the team at having made a really big contribution to that achievement.
Wow, it must have been amazing to hear people say we need to fix this problem and then just a few years later see children being vaccinated.
Yes, it was, for the whole team. I think the thing that pulls people to work at IVAC more than anything is the mission. It's a mission-driven group, they are committed to the notion that we can do something about vaccine access. And when we do, it makes a difference in peoples lives and communities. There are lots of organizations that talk about that, and here we have the privilege and benefit to actually deliver on it. That’s one of the things that make IVAC special.
While we are talking about the mission, what do you envision in the future for IVAC?
IVAC is in a terrific position. The number one strength of IVAC is its team. We have incredibly talented people here who are going to carry the mission forward for years to come. You know, I see many opportunities for IVAC in the future. Really the question that IVAC probably will face is, out of so many opportunities, which do they choose to focus on? It’s a good problem to have.
What are the things you value most about the team here at IVAC?
One of the things that make it hardest to leave is the team. There are a few people who have been with me shoulder-to-shoulder from the beginning, like Kate O’Brien, Mathu Santosham and Maria Knoll, and others like Dagna Constenla, Danny Feikin and Lois Privor-Dumm, who have come on board later. What is really remarkable in many ways is that as we grew we retained a core set of ambitions: a sense that we didn't want incremental change, we wanted that big change, and that it was possible; a willingness to question things, not in an arbitrary or personal way, but in a very results-focused way;
Dr. Orin Levine and members of the PERCH Expert Committe at a meeting in Baltimore in 2012. (Photo Credit: IVAC)
and an innovation-centered approach, that idea that if it was easy it would have been done already, so let’s try something a little bit different. Those are some of the things that IVAC is going to carry forward, especially this sense of bringing innovation to difficult problems and the willingness to experiment and fail, which is integral to making a difference.
What’s your vision for vaccine access in general? What changes do you think we will see in the next 5-to-10 years?
It’s an exciting time to be working on vaccine access. There are some really important trends that are going to impact vaccine access in the years to come. From my perspective, one trend is going to be an emphasis on more and more country-driven immunization programs. Countries are going to be less reliant on donors and international agencies and more self-reliant. That's a great opportunity and it requires shifting towards a policy dialogue model. I also think we are moving to a more integrated approach to delivering interventions within health and even between health and other sectors. So you are seeing things like financial services and health connecting. And then the last area that I think is going to be really exciting is improving service delivery. We have improved our vaccine introduction and accelerated that more in the last decade than we have improved coverage or service delivery. We made big gains by narrowing the time-lag in access to new products, but the next big step is going to have to be boosting us to universal coverage in every community.
So what excites you the most about your new position?
I think working at the Bill & Melinda Gates Foundation will be exciting because of their results-based approach to tackling problems. The foundation brings to bear great minds, substantial resources, and a prolonged focus.
And you are moving to Seattle. What are you looking forward to about that? Aside from the rain...
Well, the well-known weather patterns of Seattle are certainly a draw. The city itself is really beautiful and, for me and my family, who really enjoy the outdoors, there is just tremendous opportunity to enjoy the Seattle environment. I think we – me professionally and hopefully my family too – both literally and figuratively, will have new hills to climb that will make us stronger and bring us new rewards.
Graduate students in JHSPH’s Vaccine Policy Issues class examine current national and international policy issues across the spectrum of vaccine work. As a part of the course, students selected topics for analysis. Selected entries will appear in a series on the IVAC blog. This is the final of the series.
Guest post by Shreya Patel, MPH
More often than not, these are dreaded words for significant others, employees, and teenagers everywhere. I, however, am not your significant other, boss, or parent. For this discussion, you can call me Switzerland and I am going to be metaphorically sitting directly between parents and pediatricians (ironically, that is often also my physical location as the slightly awkward fourth-year medical student). I am here to tell both parties that we need to talk. For one minute, let’s pretend that we are not warring factions. We will not (figuratively) stick our fingers in our ears and say “la la la, I can’t hear you” while the other party speaks. We will not mumble confusing jargon or excuses or insults. We will not storm out of the office. Ground rules clear? Now for the topic: vaccinations.
Vaccines protect a society from diseases through herd immunity. The more vaccinated people, the less likely a disease will spread. In today’s global society, infectious diseases can jump between continents with a boarding pass and unvaccinated children are suffering. Studies have shown that unvaccinated children are 35 times more likely to contract measles, 6 times more likely to have had pertussis, and 23 times more likely to get whooping cough compared to their vaccinated counterparts. Between January and April 2008 in the US, there were five measles outbreaks and 64 cases; all but one of the cases were either unvaccinated or did not have evidence of immunization. US vaccine exemption rates have been on the rise in the last five years with ten states increasing more than 1.5% and Alaska winning the unfortunate prize of the highest exemption rate in 2011 with 9% of its children currently unvaccinated. Vaccines have all but eradicated diseases that plagued our society in the past; but like any medicine, they only work when taken. So let’s start the discussion.
The author, Shreya Patel.
Parents, I sympathize. Aside from the physical and emotional stress of 2 AM feedings, tantrums over dinner, and your child’s first day of preschool, you are in a twenty-first century world bombarded by more information and opinions on how to raise your child than the average parent from the fifties received in a year. You rightfully worry about everything from what your child is watching on television to what they will be when they grow up. However, first and foremost, you value your children’s health. A physician offering to stick a needle into your child’s arm full of inactivated diseases and other components is certainly a scary thought. Many of you agree that vaccinations are helpful, but worry about their safety. Granted, the risks of being unimmunized in a well-immunized community are low (albeit not as low as an immunized child). So this is where it becomes vital to have a conversation with the only other person as invested in your child’s health as you, your pediatrician. The Internet is an extremely valuable resource for anything from news to celebrity gossip, but is also an open arena for anyone’s opinions, sometimes reading like a sequel to the Rocky Horror Picture Show. Making a decision about vaccinations without talking to your pediatrician is akin to determining how big the universe is without talking to your local expert physicist.
Pediatricians, I sympathize about your job, too. A seemingly endless stream of cranky children coughing in your face, all who must be seen, evaluated, and treated almost immediately in order to move on to the next. Comparatively underpaid and overworked, amazingly, you still know exactly what tricks make even the most terrified child smile. Then, in the middle of your busy day, comes a parent staunchly refusing a medical intervention you and every major medical society in the world recommends. It is often too easy to quickly dismiss them as uneducated, ignore their fears completely, or worst, immediately surrender to their medical opinion over your own. However, while it may seem like you are going to battle with the parent, in reality, you are protecting the health of the child. Refusing to address parental concerns in a calm, respectful manner is not in the best interests of your patient, their parents, the medical profession, and even public health in general.
Conflict resolution specialists use a concept called perceived or enlightened self-interest. To maximize one’s own self-interest in a disagreement, it is generally necessary to recognize the self-interest of the other party and understand that there are solutions where both parties will be satisfied. Instead of parents and pediatricians approaching the conflict from opposite ends of a football field, what if instead, they started on the middle ground where the both agree? Both primarily want to ensure children are healthy and safe. They want children to avoid disease, grow and develop properly, and become productive adults. With so many fundamental, common self-interests, why are so many not even willing to start the conversation?
While my personal opinions on the matter have been revealed, I still consider myself in the middle of this argument and too often watch as both parties give up on the health of their children before any discussion. Parents, make a separate appointment to discuss your concerns and choose a new pediatrician if they refuse to talk with you. Your pediatrician has your child’s best interest in mind, years of education and experience, and hopefully, would like to work with you to come to a decision you are both comfortable with. You have a personal expert at your fingertips. Why resort to celebrities for your medical advice? Pediatricians, do your own homework on the evidence behind vaccine safety or rates of vaccine-preventable diseases. Remember that parents may be misinformed or scared and would like a forum to discuss their concerns. In the end, there will always be a minority who will still refuse vaccines. As someone about to enter the field of medicine and public health, my hope is simply that all parents make their decision with a full understanding of the risks and benefits after an informed discussion with their medical provider.
Shreya Patel completed her MPH at Johns Hopkins Bloomberg School of Public Health in May, 2012, focusing on international health, vaccine policy issues, and epidemiology. She is currently a fourth-year medical student at the University of Arizona College of Medicine and plans to enter the field of Internal Medicine for residency in 2013.