RotaFlash, April 2016
If diarrhea is public enemy number 2 (pardon our toilet humor!), vaccines are one of the superheroes in our fight against this fierce foe. In areas with limited access to clean water, sanitation, and hygiene, diarrhea can hold communities hostage with the heaviest burden falling on children who routinely ingest diarrheal disease pathogens in their environments. The four most common pathogens causing diarrhea are rotavirus, enterotoxigenic Escherichia coli (ETEC), Shigella, and Cryptosporidium.
Repeated infections from these and other pathogens not only make kids chronically sick, but can create a hole in family budgets. On top of long-term economic consequences, chronic stomach bugs can result in long-term harm for the child, in the form of environmental enteropathy, a condition that prevents proper nutrient absorption, impairs immune system function, and can lead to malnutrition and stunting. These effects are particularly damaging in children under age two whose bodies and brains are undergoing rapid growth and development. When children miss early opportunities for growth, the effects are irreversible. This diminished cognitive and physical development creates a ripple effect through society that hampers the financial health of communities, as well as emerging economies.
Prevention through vaccination is a critical part of the strategy to reduce the impact of diarrheal disease in low- and middle-income countries. Vaccines against rotavirus, the leading cause of severe, deadly diarrhea worldwide, are already making impressive gains in countries where they’ve become a part of routine immunization programs. Currently, no licensed vaccines for diarrhea resulting from the bacteria ETEC and Shigella or the parasite Cryptosporidium are available—but ETEC and Shigella vaccines are on the horizon.
This week, PATH is convening the inaugural Vaccines Against Shigella and ETEC (VASE) Conference in Washington, DC, focused on the two leading bacterial causes of moderate-to-severe diarrhea. Researchers from around the world will convene to share knowledge and join forces against these foes. We think scientists are superheroes, too, and recently they shared with us why the fight against bacterial diarrhea, particularly ETEC and Shigella, is so important.
Vaccines are an essential part of a strategic approach to reduce deaths from diarrhea and prevent the irreversible harm caused by chronic illness, but vaccines alone won’t give diarrhea the one-two punch we need to defeat diarrhea. It will take a proven integrated approach joining Vaccines with fellow superheroes clean Water, Sanitation, and Hygiene (WASH), Nutrition, and ORS/Zinc to loosen diarrhea’s grip on low-resource communities around the world.
You can be a superhero too! Use #DefeatDD to tell us how you think an integrated approach made up of WASH, Nutrition, ORS/Zinc, and Vaccines could make a difference for children around the world. And stay tuned for the release of Superheroes versus Villains: The Diarrheal Disease Edition, our blockbuster feature highlighting the four primary causes of diarrhea and the ways an integrated approach can stop these pathogens in their tracks for good.Read more
This graphic appears in USAID's 2016 Acting on the Call Report.
“This is the story of my life, and it begins the same as everyone else’s,” says the narrator of “To Keep a Promise.” It’s sweeping and intimate all at once, because it tells the human story: how each of us relies on many hearts and hands to grow up safe, healthy, and whole.
And it is true that for all of us, life begins the same way: the first breath. The cutting of the cord. But the promise of health and of safety, birthrights that are as fundamental as that first breath, remain out of reach for much of the world.
USAID’s 2016 Acting on the Call report looks at sources of inequity in maternal and child health and how the US government is working to address them. For example, the Water for the World Act, passed in 2014, calls for a focus on the poorest communities, and this report notes the global trend toward urbanization is a growing consideration in these efforts. It also acknowledges the inherent linkages of diarrheal disease and other health issues, incorporating “nutrition-sensitive” interventions like WASH into USAID’s Multisectoral Nutrition Strategy. Case management for the treatment of pneumonia and diarrhea and equitable access to vaccines are also key themes.
The rallying cry in this report and in maternal and child health overall is: “We’ve made great progress, but there’s still work to be done.” The shift in the diarrheal disease burden is one chapter in that story: Fewer children are dying from diarrheal disease, yet if those who survive get sick repeatedly in their critical early years, the long-term physical and cognitive growth shortfalls can hold them back for a lifetime. We are clearly not finished yet.
My heart swells with pride when I think about the US efforts to extend our nation’s collective heart and hands to heal the most vulnerable and create a more stable, prosperous world. It’s no wonder that maternal and child health enjoy strong bipartisan support. You can help strengthen the US government’s efforts in maternal and child health by asking your Member of Congress to support the Reach Every Mother and Child Act. It takes a global village of hearts and hands, after all – yours included.Read more
A first photo of my hours-old niece, who joined the world in April 2013.
“Aunt Hopey, stand UP!” commands my three-year-old niece from atop her parents’ bed, pulling me up into her imaginary kingdom (with surprising force, I might add!) and leading the way as we stomp in a circle and shout together an authoritative staccato refrain: “March! March! MARCH!” (Pro tip: Don’t introduce a little one to a new game unless you are willing to repeat it several hundred times.)
I wonder to myself, yet again, is this the same little person I held in my arms as a cooing, helpless bundle two and a half years ago, now giving playful orders, walking and running and marching?
Anyone who has parented (or helped nurture) an infant is an intimate witness to the unbelievable changes that occur within the first few years of life. The physical and cognitive growth in this phase is unmatched in its intensity – so much so, that if children don’t absorb enough nutrients during this window, they carry the damage with them throughout their lives. Good nutrition is a matter of utmost urgency, explains Dr. Roma Chilengi.
Addressing malnutrition might seem straightforward on the surface – more fruits and vegetables seems simple enough – but the reality is that this won’t completely, or even nearly, fix the problem. In fact, according to the 2016 Global Nutrition Report, direct nutrition interventions, even when applied at a 90% coverage rate, addresses only 20% of the stunting burden.
At DefeatDD, we spend a lot of time thinking about the essential role of safe drinking water, sanitation, and hygiene (WASH) on nutrition, and we were thrilled to see that this year’s Global Nutrition Report gives special attention to WASH as an “underlying driver” of stunting outcomes.
You see, diarrheal disease – caused in large part due to poor access to WASH – and malnutrition are inextricably linked. One of the most unforgiving examples of this is a condition called environmental enteropathy (EE): damage to the gut caused by ingesting enteric pathogens in the environment. Once this happens, a child may receive nutritious food, but EE prevents the absorption of nutrients. It’s one reason why malnutrition can be so difficult to treat. Like many health-related solutions, we can’t lose sight of the fact that the answer is a multi-faceted one; I’ve never met a child whose life fit neatly into health intervention buckets, have you?
Thanks to her loving family and access to her basic needs, my niece marches strongly through toddlerhood.
“Though she be but little, she is fierce,” said William Shakespeare about my niece (okay, so maybe it was about Hermia from A Midsummer Night’s Dream). I know that her fierceness is possible because my family had the resources to give her body and mind the strength to become so. And I think it’s only fair that other fierce little girls and boys have an equal shot to become their strongest selves, too.
I believe my niece might suggest a march as part of the solution.Read more
His Excellency Ibrahim Boubacar Keita, President of the Republic of Mali, at the Opening Ceremony of the 10th African Rotavirus Symposium. Photo credit: Mama Traoré and Kamory Diallo.
Living and working in Mali, I have seen many family members, friends, and patients suffer from severe diarrhea. My brother nearly died from diarrhea as a young child and I will never forget my mother’s worry. Far too many Malian children lack easy access to medical care and die needlessly from vaccine-preventable diseases.
Our goal at the Center for Vaccine Development (CVD) – Mali is to prevent, control, and treat endemic and epidemic infectious diseases, particularly those that are vaccine-preventable. We were honored to have hosted the 10th African Rotavirus Symposium in Bamako, Mali on 1 – 2 June 2016. Over 150 people from 33 countries, 29 in Africa, joined forces to address the theme “Reaching Every Child in Africa with Rotavirus Vaccines.”
Dr. Samba Sow, Director General, CVD-Mali and Duncan Steele, Deputy Director and Strategic Lead for Enteric Vaccines, Bill & Melinda Gates Foundation. Photo credit: Mama Traoré and Kamory Diallo.
This year’s symposium, the first held in francophone Africa, occurred at an unprecedented time when 30 African countries have introduced rotavirus vaccines into their national immunization programs. The opening ceremony led by His Excellency Ibrahim Boubacar Keita, President of the Republic of Mali, and Dr. Marie Madeleine Togo, Minister of Health, marked this historic event. During the ceremony, attended by more than 400 dignitaries, government officials, and symposium attendees, there was an outflowing of praise for the leadership and dedication of the Malian government in introducing rotavirus and other lifesaving childhood vaccines and catalyzing introductions in other African countries.
Scientists, clinicians, public health officials, policymakers, vaccine manufacturers, and international rotavirus experts discussed diarrheal disease burden, rotavirus vaccine effectiveness and safety, advances in rotavirus science, and sustainability of vaccine programs and diarrhea control efforts in Africa. Rotavirus prevention, through vaccination, is critical to saving children’s lives in countries where health care is inaccessible, unavailable, and/or cost prohibitive.
The symposium organizers issued a Call to Action to: introduce rotavirus vaccines to the 22 African countries that have yet to introduce the vaccine and expand access in the countries that have introduced it to reach all children; continued surveillance and post-impact evaluations; new research in strain diversity, effect of the microbiome, and alternative schedules and doses; and the need to prioritize financial planning.
The popular saying that “it takes a village to raise a child” applies to this event, which would not have been possible without its organizers and sponsors. CVD-Mali will continue to work tirelessly to train and educate health care professionals, and to test the safety, immunogenicity, and efficacy of vaccines. We must not stop until we reach every child in Africa with rotavirus and other lifesaving vaccines.
A proud new mother in India cradles her newborn. Photo credit: Richard Franco.
Baby Whitney arrived fourteen weeks early in 1980. Her mother Lisa Kidd traded visions of first snuggles in a newly minted home nursery to long days and nights at the neonatal intensive care unit (NICU) of Portsmouth Naval Hospital in Virginia. More than two hundred miles from home, what the hospital lacked in convenient location it made up for with the region’s leading technology and expertise. Far from their families, Lisa and the other NICU moms supported one another through some of their most harrowing days. But round-the-clock vigilance was not feasible for everyone, and when many mothers had to leave for trips home or others could not even afford travel to the hospital, Lisa extended support to her new community – she donated her excess breast milk. (Full disclosure: Lisa is not only a generous and fantastic mother; I can directly attest that she is a great mother-in-law too).
Human milk is the single most powerful intervention to save babies’ lives, providing the unique nutrition and immune support they need to survive and thrive. Compared with formula, according to the American Academy of Pediatrics, breast milk reduces the risk of sepsis and necrotizing enterocolitis in neonates, reduces the time hospitalized infants remain in care, and reduces feeding intolerance, diarrhea, gastric issues, and other dangers. But while breastfeeding may seem like a simple, straightforward—not to mention rigorously scientifically proven—intervention, neonatologists worldwide report that between 15 to 40% of infants in NICUs do not have access to their mothers’ milk.
The World Health Organization recommends the safe use of donor milkfor vulnerable babies who cannot be fed their mother’s own milk. When a mother has died or has a health issue that makes breastfeeding impossible for either short- or long-term, donor breast milk is a safe and effective alternative. Facilities pasteurize donated milk to ensure it is safe, and then freeze it until needed. However, scaling up this lifesaving intervention has been challenging in poor countries.
Hospitals in low-resource settings face technological barriers to safe milk banking (more on that later), and challenges persist among communities in the general population, as well. Inappropriate, aggressive marketing of breast milk substitutes like infant formula can undermine parents’ confidence in breast milk and distort perceptions. Lack of awareness is a crucial contributor to the alarmingly low rate of exclusive breastfeeding (37%) in low- and middle-income countries. In fact, the WHO International Code of Marketing of Breast-milk Substitutes calls on countries to protect breastfeeding and enact laws against the inappropriate marketing of breast-milk substitutes, feeding bottles, and teats. When breast milk substitutes are necessary, the code aims to ensure they are used safely. A new report provides an update on country-specific progress to enforce laws on marketing breast milk substitutes.
Appropriate infant and young child feeding, including breastfeeding, is so essential that efforts must extend beyond a single intervention to promote a shared understanding of its value and make the case for sustained investment. Through our Mother and Baby Friendly Initiative Plus, PATH applies a comprehensive model for improving infant and young child feeding practices, including increased access to donor breast milk for at-risk mothers through human milk banking. Our projects in South Africa, India, Kenya, and Vietnamfocus on developing locally adapted, government-led, quality systems for ensuring safe access to human milk for all infants. We are also working on innovative and cost-saving technologies for low-income settings, like our mobile-phone app that directs and monitors a simple flash-heat pasteurization process and a rapid, point-of-care diagnostic device for screening donations. On the flip side, for a smaller group of infants who have difficulty breastfeeding, such as those with cleft-palate or who are born pre-term, we are partnering to accelerate access to the NIFTY cup, which features unique reservoir and flow channels that allow infants to lap or sip at their own pace. This comprehensive approach also prioritizes caregiver counseling on infant and young child feeding practices and kangaroo care (skin-to-skin contact). Counseling emphasizes WHO recommendations for exclusive breastfeeding during the first six months, addresses problems with breastfeeding including insufficient breast milk, and highlights complementary breastfeeding through two years of life.
In Kenya, we are documenting improvements on exclusive breastfeeding rates through the Baby Friendly Community Initiative, funded through the USAID Maternal and Child Survival Program (MCSP) and conducted in partnership with the Ministry of Health and UNICEF. Success at the community level is informing the development of an implementation package to guide scale-up. Through MCSP, PATH is also working to revitalize the Baby Friendly Hospital Initiative in Malawi in partnership with Ministry of Health, partner organizations, and WHO. But these interventions can only be taken as far as government commitments, resources, and funding allow. That’s why PATH is helping to promote supportive policies that enable countries to set aside targeted resources for comprehensive breastfeeding strategies.
Evidence is overwhelming for the pivotal benefits of a mother’s milk, and when a mother is unable to provide her own, ensuring access to safe donor milk helps keep this promise of a healthy start to vulnerable infants. This network of care—built on the generosity of mothers like Lisa and her peers around the world—can save lives simply and safely. But it is only as strong as the comprehensive programs and policies that sustain it.Read more