RotaFlash, August 2014
Rotavirus vaccines have been introduced in Niger and Eritrea, bringing the global...
It all seemed that it would be easy back in 2006. The New England Journal of Medicine published landmark articles reporting the safety and efficacy of two new rotavirus vaccines in January of that year. And within weeks the US announced that it would recommend one of these vaccines for routine use in all US infants. Within months other countries in Latin America followed suit announcing inclusion of rotavirus vaccines into their National Immunisation Programmes (NIP). By 2007 there were over 25 countries that became “early-adopters” of rotavirus vaccines. But then progress appeared to slow rather than accelerate.
The ground work had appeared to have been well laid to help public health policy-makers in all other countries to quickly follow with similar recommendations to rapidly introduce rotavirus vaccines. “Proof of local disease burden” and “evidence of cost-effectiveness” were identified as key information that would drive policy decisions on vaccine introduction. From the late 1990s, the World Health Organisation (WHO) and the US Centers for Disease Control and Prevention (CDC) facilitated the establishment of regional Rotavirus Surveillance Networks to collect this all important disease burden data. The Asian Rotavirus Surveillance Network was the first to be formed in February 1999. A range of high-, middle- and low-income countries in the Asian region started to collect information on how many children were admitted to hospital with diarrhoea and the proportion of these admissions that were due to rotavirus. A WHO generic protocol to collect these data was simple to follow and required that participants only needed to select a small number of sentinel surveillance hospitals.
As more and more data emerged showing the rotavirus virus was the dominant pathogen causing admission for diarrhoea in children under-five years of age, it seemed more and more likely that decision-makers would enthusiastically embrace these new vaccines. The WHO made a recommendation in 2007 that rotavirus vaccines should be considered for inclusion in the NIPs of countries were efficacy had been demonstrated. This essentially meant the Americas and Europe, as these were the sites of the initial efficacy studies published in the New England Journal of Medicine. However by 2009 data became available from studies done in Asia and Africa and the WHO updated its recommendation to advise that rotavirus vaccines should be included in ALL NIPs, and for those countries with high mortality from gastroenteritis in children under five years old, the WHO emphasised that the vaccines were STRONGLY recommended.
Yet despite this unequivocal recommendation, the response from many Health Ministers, vaccine advisory committees, and public health officials has been somewhat underwhelming. There was no clamouring to obtain the rotavirus vaccines following the announcement of the WHO recommendation. Yet 2009 was the same year that many Health Ministers were rushing to buy stockpiles of pandemic H1N1 influenza vaccine – at a stage in many countries when it was already obvious that the likely impact of this virus on mortality would be no greater than that of normal seasonal influenza. Why the urgent high-level meetings to discuss influenza vaccine but not similar meeting to discuss how to expedite introduction of these important new rotavirus vaccines?
Some “early-adopter” countries (Australia, Austria, Belgium, Brazil, El Salvador, Mexico, Panama, and the US) have witnessed approximately 70% fewer hospital admissions due to rotavirus illness and approximately 35% fewer hospital admissions due to diarrhoea of any cause during the first two years of life. In high- and middle-income countries gastroenteritis can account for around 15% of all general paediatric admissions in children under five years old. If we could reduce these admissions by 35%, it means that overall there will be 5% less paediatric admissions every year. This is a massive effect. Think of the impact on the front-line medical and nursing staff. Think of the impact on hospital beds. Think of the reduced risk of nosocomial infection. Hospital Administrators should be jumping up and down demanding that rotavirus vaccines be introduced as quickly as possible. Sadly they don’t yet seem too excited about this potential intervention that could boost their limited resources.
In 2008, there were an estimated 453,000 deaths from rotavirus in children under-five years, making it one of the leading causes of death in this age group. In Asia in the same year there were an estimated 188,000 deaths from rotavirus. This is equivalent to about 500 child deaths every day. Nearly 95% of these deaths occur in the low-income developing countries where access and availability to health care is limited. Even if the Health Ministers of these poorer developing countries do not have the resources to immediately include rotavirus vaccines in their NIPs, one would at anticipate (naively) that rotavirus vaccine introduction should be high on the Agenda of every G8 meeting – ahead of the GFC (global financial crisis) and similar mundane topics.
2.4 million child deaths could be prevented by 2030 by accelerating the introduction of rotavirus vaccines. To achieve this goal GAVI and its partners plan to support the introduction of rotavirus vaccines in at least 40 of the world’s poorest countries by 2015, immunising more than 50 million children. GAVI initially gave support for rotavirus vaccines in 2006 and since then, introductions have occurred in Nicaragua (2006), Bolivia (2008), Honduras (2009), Guyana (2010), Sudan (2011), Ghana (2012), Rwanda (2012), Moldova (2012) and Yemen (2012).
As of August 2012, 41 countries have introduced rotavirus vaccines into their NIP. Although many countries in Latin America started using rotavirus vaccines in their NIPs more than 5 years ago, no country in Asia had done so until the Philippines announced in January 2012 that it planned to vaccinate an estimated 700,000 children annually from the poorest communities. Thailand is the second country in Asia to announce the partial introduction of rotavirus vaccine into it’s NIP (Sukhothai Province). Currently no GAVI-eligible Asian country has introduced rotavirus vaccine.
Clearly Asia needs to do more and try harder – and to do this quickly. It has lost the opportunity to be an “early adopter” region – let’s hope that Asia won’t be known as the “last-adopter” region.Read more
Social entrepreneurs with boundless creativity are redefining the outer limits of what’s possible in global health. Two such visionaries, Simon and Jane Berry, have harnessed their mental oomph and creative prowess in the public health community in Zambia to address one major global health dilemma: access. They tasked themselves with the following: identify an existing distribution channel whose reach is vast, design an innovative commodity that is culturally relevant with user-friendly messaging, and enroll champions along the supply chain instrumental to product delivery in target communities.
Who has the farthest reaching arm to even the most remote villages in Zambia and in much of the world? Coca-Cola. A willing partner, but not extensively involved in the project, Coca-Cola agreed to let ColaLife, Simon and Jane’s organization, piggy back on their existing end-to-end supply chain to deliver life-saving public health treatments: oral rehydration solution (ORS) and zinc.
Packaged in a tidy reusable plastic cup with pictorial, culturally appropriate instructions and hygiene messaging, along with a bar of soap to boot, the AidPod is a wedge-shaped container that fits between glass Coca-Cola bottles inside of a plastic Coca-Cola crate. One AidPod contains 8 200ml packets of ORS and 10 tablets of zinc. Local testing determined the kits should be locally labeled Kit Yamoyo (Kit of Life) anti-diarrhea kit.
ColaLife enrolls and motivates champion distributers to ensure the product reaches the market at the far and remote end of the supply chain. Each kit is labeled with a number, which is tracked via cell phone to monitor and create real-time sales and distribution data. Health promoters, such as community health workers, can also receive feedback regarding uptake in any given community.
“I was reading in the paper, and there, page 3, lower corner, '1 in 5 kids will die before their 5th birthday' and I thought, can that really be, 1 in 5?” Simon reflected. “When someone said they are going to put a brown fizzy water [Coca-Cola] in a glass bottle in a plastic crate and send it to the outer reaches of the earth, I’d have said no way is it possible. This, what we are attempting to do, should be a no brainer.”
Access to basic solutions to prevent deadly diarrhea, such as zinc and ORS, remains elusive to many households in peri-urban and remote rural communities. Misunderstanding and misuse of products that do exist in the market complicates the situation. Simon and Jane are reducing child mortality due to dehydration and diarrhea among the most isolated and underserved communities by creating access to a user-friendly, culturally relevant, and affordable public-health intervention.
We salute you, Simon and Jane, two champion social entrepreneurs who don’t waste time, who create novel public health approaches, and who, with their hearts of gold, enroll public & private sector partners to deliver desperately needed solutions to isolated communities, where the impact will be great.
-- Lisa Anderson is a Program Assistant for Vaccine Development at PATH
For more information:
See other blogs inspired by defeatDD's trip to Zambia:
-- Soccer goals and other victories: Ministry of Health official Vichael Salavwe recalls a moment that inspired his career path.
-- Defeating a leading child killer in Zambia: The country prepares for a national rotavirus vaccine rollout.
-- Finally, firsthand: After 10 years in development work, Deborah Phillips visits an African clinic for the first time.
-- On balance and empathy: It really is a small world after all.
-- Diving into Zambia's water challenges: Not literally!
Photo credit: PATH/Gareth BentleyRead more
Exclusive breastfeeding for six months is one of the most effective ways to reduce a child’s risk of diarrheal disease. In fact, up to 55 percent of infant deaths from diarrheal disease and acute respiratory infections may result from inappropriate feeding practices.
But many mothers throughout the world do not choose this life-saving practice because they don’t have adequate social support. Outside influences—like misleading advertising of breast milk substitutes, or having to return to work before six full months of exclusive breastfeeding—can prevent mothers from making the best feeding choices for their infant.
This June, Vietnam’s National Assembly voted in two landmark decisions for national-level policy changes to help create that support for mothers and families. On June 18, the assembly voted to extend paid maternity leave from four to six months. The new policy, which takes effect May 1, 2013, is a bold departure from other maternity leave policies in Southeast Asia.
Three days later, the National Assembly voted to expand the ban on the advertising of breast milk substitutes for infants from six to 24 months, including teats and bottles, and to ban advertising of other nutrition products and foods for children under six months. The decision aligns Vietnam’s Advertisement Law more closely with the International Code of Marketing of Breast-milk Substitutes, and will help ensure that mothers and families receive more accurate and unbiased information about how to feed their children.
Both policies passed with more than 90 percent of the vote.
The success was the result of a large collaborative effort between the National Assembly, government agencies, UNICEF, WHO, Alive & Thrive, and local advocacy partners. Each partner either led or shared significant responsibility for specific activities—whether conducting research and establishing the evidence base, performing policy and legislative analysis, creating compelling communications materials, liaising with relevant partners or legislative agencies, or building consensus through workshops and seminars. Throughout the process, the media was engaged to tell the story of the impact of poor infant and young child feeding on health and development outcomes.
Infants are at greatest risk of diarrheal disease when foods other than breast milk are given. And when breastfeeding stops, infants lose the protection of breast milk’s anti-infective properties. With policy changes like these, no Vietnamese mother will have to decide between her job and the health of her child.
Read more about how the policy changes came to pass at AliveandThrive.org.
Photo credit: Vu Hai ChauRead more
Where else but a Toilet Fair could one encounter an evening of stimulating conversation… about poop? The Bill & Melinda Gates Foundation proudly presented the chance to mingle with some of the most innovative, creative minds applying their intellectual heft to the world’s sanitation problem. Here we share our impressions and take you on a vicarious visual tour of the engineers who answered the call of Gates’ Re-invent the Toilet Challenge.
Yum! Tiger worms are experts at chowing on trash to digest and turn it into compost, and the London School of Tropical Medicine and Hygiene is bringing them to bear on human waste.
The Tiger Toilet (seen here in prototype) would hold up to 1,000 worms, with human waste and natural fibers creating a viable ecosystem throughout the worm’s lifecycle. The worms digest 95% of the waste, which then would become fertilizer, supporting agriculture throughout the local community.
Hygiene translates in any language. Educational books and videos teach kids about the importance of sanitation.
From waste product to clean water. The VUNA project is testing reactors that nitrify, distill, precipitate, and electrolyze urine, turning waste into resources. The ultimate result? Fertilizer and distilled water. (VUNA partners include eThekwini Municipality in Durban, South Africa; the University of KwaZulu-Natal; the Swiss Federal Institute of Aquatic Science and Technology; and the Swiss Federal Institute of Technology Zurich.)
Another team at the University of Kwa-Zulu Natal is working on a toilet that will separate human waste from other garbage thrown in, to facilitate processing into fertilizer. They’re also researching what gets thrown into latrines and toilets in low-resource areas so they can better design their separating toilet. As one researcher said, “What goes into the toilet is, right now, a black hole of data.”
In WASH United, we found kindred spirits. They’re determined to use fun, positive messages, paired with soccer and cricket stars, to get kids excited about hygiene and sanitation. In October, their Great WASH Yatra will feature a travelling carnival that will cross the country over 45 days with games and Bollywood performances that highlight handwashing, clean water, and safe sanitation. Score!
The World Toilet Organization spreads a serious message… but they can never resist a little potty humor. We loved these stickers that were slyly hidden on a staircase!
Forty percent of the global population has nowhere to privately and safety go to the bathroom. Disgusting, right? If you want to add your voice to call for safer sanitation, talk sh*t with your own communities today!Read more
As doctors and researchers, we have spent our lives treating sick children and consoling families rocked by illnesses and deaths that could have been prevented. Too many times, we have lost patients to preventable causes like diarrhea.
But when it comes to rotavirus, the most common cause of severe childhood diarrhea, we’re turning the page – helping to protect children by encouraging every nation to introduce rotavirus vaccines. They are safe, effective tools preventing illnesses and deaths with dozens of studies demonstrating their impact. In fact, our colleagues have found that rotavirus vaccine use has led to significant reductionsin hospitalizations and deaths not just due to rotavirus, but all causes of diarrhea in many of the countries that have introduced rotavirus vaccination.
Evidence like this is critical to global efforts to ensure rotavirus vaccines are reaching all of the children who need them. For this reason, the Rotavirus Organization of Technical Allies (ROTA) Council,which we co-chair, is working to provide policymakers with the evidence needed to inform decisions related to vaccine introduction. We are calling on policymakers to expand the use of rotavirus vaccines and make diarrhea illnesses and deaths a thing of the past. And we are working with partners, like PATH,to spread the word that rotavirus vaccines are an important part of a comprehensive approach—one that includes interventions like oral rehydration therapy and zinc supplementation— to combatting diarrheal disease.
As recent rotavirus vaccine introductions in the Philippines and Yemen demonstrate, leaders in more and more countries around the world are prioritizing rotavirus prevention. As of August 2012, 41 countrieshave introduced rotavirus vaccines. Tremendous progress is being made, but there is still work to be done.
Time and time again, we have seen the quick, and often deadly, turn that rotavirus can take in countries where children are not protected through vaccination. Ninety-five percent of rotavirus deaths take place in countries eligible for vaccine introduction support from the GAVI Alliance. But today, many of the developing countries that stand to benefit most have not yet introduced these vaccines. As our colleagues reported recently in the journal Vaccine, “documenting the anticipated health benefits of vaccination in these settings will be key to sustaining and encouraging broader use of rotavirus vaccines.”
We call upon governments to prioritize the introduction of rotavirus vaccines and invest in national health systems. The saying goes that a nation is only as strong as its health system—and health systems require innovation and investment to thrive. Systems with appropriate funding, staff, communication, supplies and equipment are best positioned to deliver the protection of vaccines to children, fight poverty and foster development.
The scientific community is doing its part—providing the evidence needed for decision making—and it must continue these efforts. Now, it’s time for broader global health community to help ensure decision makers are being reached. More voices are needed so that more countries heed the call for the introduction of rotavirus vaccines. Working together, with a chorus of voices, we can ensure decision makers understand the burden of rotavirus and promise of vaccines.
Will you join us?
-- Dr. Ciro A. de Quadros, Executive Vice President of the Sabin Vaccine Institute, and Dr. Mathuram Santosham, Professor of International Health and Pediatrics at the Johns Hopkins Bloomberg School of Public Health, are Co-chairs of the Rotavirus Organization of Technical Allies (ROTA) Council, a dedicated team of technical experts focused on saving lives and improving health by promoting the use of rotavirus vaccines as part of a comprehensive approach to addressing diarrheal disease.Read more