RotaFlash, April 2016
Outbreak and emergency situations often raise the specter of cholera and the very real danger it poses. But many communities throughout the world also face the silent, but no less deadly, burden of endemic cholera. Earlier this year, results from a groundbreaking study showed the promise and potential of using cholera vaccines for prevention in endemic settings. DefeatDD talked with Dr. John Clemens, Executive Director of icddr,b, which conducted this large scale study in Dhaka, Bangladesh.
This study was unique in its focus on preventing endemic disease, as opposed to halting the outbreaks we commonly associate with cholera. Tell us about the vaccine and the study findings.
The vaccine we studied, Shancol, was developed by the International Vaccine Institute in Korea, Vabiotech in Vietnam, and Shantha Biotech in India, where it has been licensed since 2009. It was created with the intent of affordability, with a low cost-of-goods, and logistic adaptability to the challenging conditions that often occur in cholera epidemics. It is now prequalified by the World Health Organization and is the basis for a stockpile of oral cholera vaccines.
The predominant use of the stockpile has been for outbreaks, yet over 90 percent of the global cholera burden is endemic disease. As is the very nature of endemicity, endemic cholera has a tendency to become perceived as a part of daily life, and does not attract the international attention that outbreaks attract. Shanchol has been very useful in outbreak settings, very feasibly administered and impactful. So we evaluated the vaccine to determine if it is also feasible and impactful when deployed against endemic cholera in an urban, endemic setting.
The endemic cholera burden in an urban, highly populated area like Dhaka must be quite significant.
It is a tremendous burden in Bangladesh. Even though many of the modern approaches to the treatment of diarrhea and cholera were developed here, there are several hundred thousand cases of clinically significant cholera per year, and deaths in the thousands. And in urban areas, cholera burden is growing. Rural populations are moving to the city in great numbers and creating urban squatter settlements that are densely populated, with living conditions that allow diseases like cholera to thrive.
With endemic disease throughout the population, who is the vaccine's target populaton?
Endemic cholera affects all age groups, although it occurs with higher incidence in children. The current thinking is that to immunize pre-emptively against predictable endemic cholera, programs might focus on children under the age of 15 or even an entire population, depending on the strategy that provides the needed level of protection for the population. We are planning to undertake a project with this same vaccine in urban Bangladesh to determine which is the most high-impact, cost-effective, and feasible strategy.
The vaccine is given in two doses, and re-immunization would be required three or up to five years later, depending on the age group. Young children probably will require three-year boosters. Older people seem to be protected longer, to at least five years.
What is the timeline for potentially using this vaccine for pre-emptive protection in endemic communities?
Our project aims to provide the evidence the Government of Bangladesh needs to move forward in deciding whether to incorporate cholera vaccination against endemic disease. The project is two years in duration, and we hope that by its end, we would see decisions about vaccine introduction to be made soon thereafter.
This is very exciting. People have been talking about using oral cholera vaccine in Bangladesh for many years. 30 years ago, icddr,b conducted the world’s first field trial of the efficacy of an oral cholera vaccine against endemic chollera, and there has always been hope that such a vaccine could transition into programs to control the endemic problem, especially among the poor.
So why the gap? What happened in those 30 years that we are only now coming closer to this strategy?
The vaccine that was licensed based on the 1980s field trial was safe and effective, but proved too costly for developing-country programs. Also, because it had to be given with a liquid buffer, it was challenging to administer in some settings. As well, there has been a historical tension between those favoring vaccine strategies and those focusing on controlling cholera through traditional means like improved water and hygiene and improved treatment. Of course in an outbreak, treatment is priority number one.
We have come to realize that, clearly, improved water and sanitation are the ultimate solution to preventing cholera. And vaccines are just one tool to be considered in concert with other approaches. But achievement of the levels of improvement in WASH per se that would be necessary to control cholera is probably not a near-term goal. Urbanization, for example, creates even more challenges for delivering clean water, providing good sanitation, and changing hygienic behaviors. So now there is widespread agreement that we ought to be thinking about using every tool in our toolbox to prevent cholera. In fact, there are good theoretical reasons to believe that even provision of WASH at a level that is not sufficient to control cholera may enhance the performance of oral cholera vaccine. There's inherent synergy between these two approaches.
This study was quite large, with 250,000 subjects. Is it typical for icddr,b to conduct studies at this scale? What are the keys to success?
icddrb has a history of conducting very large studies, but this is the largest vaccine study that we have ever undertaken. Proper training, supervision, and quality control are always important. But an essential component is having trusting relationships with the community. Community trust is absolutely essential. And that has been a hallmark of icddrb's work, being able to develop these relationships over the long term.
You've worked in diarrhea research, in Bangladesh, and with iccddr,b for quite a long time. What do the results of this study mean for you?
The results of this study indicate clearly that the evidence base for moving ahead in vaccinating against endemic cholera is now nearly complete. It's a very important step forward.
Photo credit: M.Dorgabekova.Read more
Official movie poster (copyright 20th Century Fox), with a few creative tweaks by Laura Edison.
With the recent NASA discovery of water on Mars, combined with the release of my new favorite movie, The Martian, Mars has been on my mind a lot lately. While watching the movie, I was struck not only by the physical beauty of both Mars and Matt Damon, but also by the incredible amount of coordination and planning that it takes to travel through space. And as a vaccine advocate, that got me thinking.
With space travel—whether fictional or real—the mission is usually to explore something, but most of the investments and planning have to do with getting there. In the case of The Martian, a fictional NASA sends a manned mission to Mars to analyze soil samples. But NASA would never send a crew of astronauts to explore Mars without a high-tech spaceship, a meticulously planned flight trajectory, and a well-trained professional team manning the control center, tracking data sent from the spaceship in order to respond as needed. The vast majority of manpower, time, and resources are spent on the journey—because no matter how exciting the goals are for the exploration of Mars, the astronauts will not be able to accomplish anything if they don’t first get there (and get home, too… cough, Matt Damon).
With immunization, our goals—such as those laid out by the Sustainable Development Goals—are to protect children from deadly and disabling diseases. But just like exploring Mars, we can’t get to that goal without the journey: getting vaccines to the right places, at the right time, and at the right temperature. This is where the supply chain comes in.
The immunization supply chain is the entire system that supports the delivery of vaccines from the manufacturer to communities. To succeed in protecting kids (or “exploring Mars”), you need not only the vaccines themselves but also cold chain equipment (spaceships) to transport them, real-time data to help decision-makers (command center) respond to changing needs, a well-planned supply system design (flight trajectory), and, of course, professionally trained supply chain workers (astronauts) to carry out the mission. Supply chains for other commodities, such as oral rehydration solution and zinc for treating diarrhea, work much the same way.
While the planning and coordination part of space travel may not be the most “exciting” part of The Martian, the mission would have been an immediate failure without it—likely resulting in deaths of the astronauts. In order to end the hundreds of thousands of real deaths of children here on earth from vaccine-preventable illnesses such as rotavirus diarrhea and pneumococcal pneumonia every year, we need to apply these same principles to immunization supply chains. I am currently working on a project that aims to use advocacy to help make that a reality.
Current supply chains are outdated and under-resourced. Problems like lack of electricity, muddy roads, flat tires, untrained and poorly paid workers, malfunctioning equipment, and paper-based data systems prevent vaccines from being delivered efficiently and effectively. By investing in next-generation immunization supply chains that include things like accessible, high-quality data, direct-drive solar-powered refrigerators, integration with other health commodity supply chains, and, where appropriate, outsourcing to the private sector, we can ensure that vaccines are delivered and their lifesaving potential is fulfilled. For example, it is estimated that, if successfully delivered, pneumococcal and rotavirus vaccines could avert more than 11 million child deaths in low- and middle-income countries by 2030.
While the real NASA has not yet succeeded in sending a manned mission to Mars, it is planning to do so in the near future (fingers crossed!). NASA doesn’t expect to get to Mars without significant investment in planning, coordination, data, training, and equipment for the journey—and the global health community shouldn’t, either. To reach our “Mars” of protecting every child everywhere from vaccine-preventable diseases, we need to get to work on the supply chain.
-- Laura Edison is a Scientific Communications Associate at PATH.Read more
On October 2nd, India celebrated its one year anniversary of the launch of the Clean India Mission. When I think about how the Government of India aligned Clean India Mission messages in all its flagship programs over the past year, especially in sanitation, I cannot help but wonder why the connection between environment and public health is so hard for people to understand.
Over the past year, I revisited places in Uttar Pradesh and Bihar where I had previously supported polio communications, which have become hotbeds of Japanese Encephalitis and Acute Encephalitis Syndrome. The cities began to look the same after a while: between no visible sign of solid waste disposal and the contamination of natural water bodies, these areas are breeding nests for a host of diseases.
The link between the polio virus and open sewage was something drilled into me while working in Uttar Pradesh eight years ago. So what can help more people, communities and governments alike, understand the connection between the environment and public health is a question that is constantly with me. Only a few months ago Delhi’s pollution levels were global news, and now the recent dengue scare has the newly appointed local Government in a twist. None of this is new; it’s just several degrees worse.
In Western India, work travel has also taken me to congested Mumbai, where innovative public health projects are faced with Herculean environment issues, even as they try to detect and treat potential tuberculosis patients.
The Prime Minister has clarified on several occasions that India’s sanitation goals have not been missed because of paucity of funds, but because the shared vision as a nation on this important issue has been missing. If one were to look at the positives, as this year rolls by, the first few critical things are seemingly in place and Clean India has caught the imagination across the country. Organizations across the spectrum have come together to work and the Clean India Mission has the highest political commitment.
Last October – on the occasion of Mahatma Gandhi’s birthday – the Prime Minister nominated well-known personalities across a wide spectrum of politics, films, and sports to be Clean India ambassadors. India has hosted international sanitation summits and these efforts are all to map the way to an ambitious goal – to achieve an open defecation-free India. These efforts will help keep India polio-free, control dengue and Japanese Encephalitis, and curb diarrheal diseases.
Despite the progress, the question still nags: Has India been doing something wrong to still be faced with this situation? What are the barriers to understanding the importance of sanitation?
For more information:
-- VIDEO: See how simple diarrhea prevention and treatment solutions can save lives in low-resource settings.
-- Help us raise awareness about the global burden of diarrheal disease. Caption our Traveling Poo's global adventures for a chance to be featured in our 2016 calendar.
Photo credit: PATH/Adriane Berman.Read more
“The results communicate a clear message: We can choose a better future for the world’s children.”
I love that sentence from UNICEF’s most recent A Promise Renewed progress report. The fact that we have a choice makes two essential points: (1) our investments in maternal and child health are working and (2) continued progress is not inevitable. We, as a global community, have to write this chapter in history for ourselves.
Practically speaking, what does that look like? DefeatDD’s new video shares our vision: Lifesaving interventions to prevent and treat diarrheal disease seamlessly woven into the fabric of healthy communities.
Looking forward begins with looking back, and just because the Millennium Development Goals have expired doesn’t mean obstacles have expired with them. It is true that thanks to progress – like the steady march of rotavirus vaccines in nearly 80 poor countries and the early achievement of the Millennium Development Goal on safe drinking water – deaths from diarrhea and other leading child killers have fallen considerably. But it would be short-sighted to consider our work finished in this arena.
While we’ve decreased the scope of the problem with simple solutions, they are not yet available everywhere, and remaining gaps reveal persistent challenges. In India, for example, while there is strong political will for sanitation through the national Swachh Bharat Mission and the India Sanitation Coalition, it has also shed light on the need for more behavior change education, creative use of limited funds, and a sustainable infrastructure that spans state and local level jurisdictions.
Globally, the changing landscape reveals that while child deaths from diarrhea have declined, a dramatic toll on children and families remains. Half a million children still die from preventable diarrhea each year, and those who do survive often are caught in a vicious cycle of diarrhea and malnutrition, suffering long-term physical and cognitive growth shortfalls. Exclusive breastfeeding and adequate nutrition are examples of simple, proven interventions that can fortify children and help ensure that they thrive, not merely survive. While we know what works, the challenge is equitable application and scale-up.
There’s also an increasing recognition of the interconnected nature of goals that, on the surface, seem unrelated. Our video illustrates how access to basic sanitation has everything to do with the education and empowerment of women and girls, and how preventing repeated diarrheal episodes can help ease families’ economic burden.
These are just a few reasons why I believe interventions to defeat diarrheal disease deserve their place in the Global Goals. Progress against this leading child killer is impressive, but unfinished. And our success here will spill over to other critical areas of health and development as well.
Help ensure that global leaders continue to focus on diarrheal disease by sharing our video.Read more
Every day, concerned families bring children of all ages to the famous Cholera Hospital run by the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). The children are brought to be treated for diarrhoea, but many are suffering from other conditions, including severe acute malnutrition (SAM). Left untreated, SAM has a fatality rate of 30-50%. But researchers and clinicians at icddr,b have developed treatment protocols and interventions that dramatically improve childrens’ chances of survival. My name is Yana and as an icddr,b staff member, I see this scene on a daily basis. I wanted to learn more about SAM and so I went into the Hospital to find out more.
Five and a half month old Alim arrives at Dhaka Hospital and within minutes is admitted by Nurse Khatun for recurring diarrhoea.
The busy hospital entrance is no easy scene to step into. At the triage counter, mothers and fathers comfort their crying children while nurses conduct preliminary assessments and register the children.
Nurse Majeda Khatun, who is on duty this day, tells me that the hospital admission process follows the World Health Organization (WHO) admission guidelines for malnutrition. These involve measuring and weighing children and checking for abnormal swelling in the feet for indicators of malnutrition. A child suspected of acute malnourishment is quickly referred to the hospital’s ‘Short Stay Unit’ for a more in-depth assessment.
The medical staff use a tablet to assess Sameha’s (pictured) z- score (weight x height) where a z-score below -3 indicates SAM as outlined by the WHO growth standards.
As I am escorted through the Short Stay Unit, the doctors tell me that “before treating children with severe malnutrition, we must treat their acute diarrhoea and existing illnesses.” We walk over to eight-month-old Sameha, who was admitted a few hours earlier. At the hospital, doctors use a tablet computer with customised software to measure Sameha’s z-score – a measure of growth - that confirms Sameha is suffering from malnutrition. One of an average 19 children per week that hospital staff diagnose with SAM, she is immediately put on a special liquid diet to increase her caloric intake, while having her diarrhoea treated with oral rehydration solution (ORS).
Azraful receives his zinc tablet from Dr. Mamun. Administration of micronutrients such as zinc in children with diarrhoea has proven to accelerate recovery and decrease chances of recurring diarrhoea in infants up to 5 years of age.
Next stop is the ‘Long Stay Unit’, where I meet Dr. Mamun. He is about to give 26-month-old Ashraful his daily zinc tablet by mixing it with a few drops of water. Dr. Mamun explains that Ashraful has a 47% higher chance of surviving while in the care of the hospital and with treatment administered according to the hospital’s SAM protocol, compared to non-standardised protocols. “Once the acute diarrhoea stops after a week of treatment of diet, antibiotics, slow rehydration, vitamins and minerals,” he says, “we will urge Ashraful’s mother to take him to the ‘Nutrition and Rehabilitation Unit’ to focus on treating his SAM.”
Saifun Nahar (left), a dedicated health worker at the NRU helps Hasan’s mother, Hahina, with feeding.
Stepping into the Nutrition Rehabilitation Unit is completely different from visiting the previous wards. The smiling and playing children in this small, 10-bed ward were clearly no longer experiencing such discomfort or pain. Right away I was drawn to 10-month old Hasan, who was on his road to recovery from malnutrition. As part of his treatment, he was being fed halwa and kitchuri, local inexpensive food items that are rich in calories and easily prepared at home. Through intense feeding over a course of three-four weeks in the hospital, the health workers and Hasan’s mother hope he will recover his lost weight and nutrients.
Hasan plays with a variety of toys as part of a scheduled psycho-social stimulation session at the Nutrition Rehabilitation Unit.
The effects of SAM can have implications well into a child’s later years of development, as malnutrition can lead to growth stunting and delays in cognitive function . At the Dhaka Hospital, nutritional rehabilitation goes beyond feeding to incorporate psycho-social stimulation of the child. For an hour each day, Hasan gets to play with cognitive-focused games, as well as home-made toys, to increase his mental development and cognitive skills. I watch Hasan as he laughs and curiously grabs every toy in sight. His mother has a smile on her face and says that she is determined to see through his recovery.
Mothers at the Nutrition Rehabilitation Unit receive daily counselling from a health worker.
An hour of each day is dedicated to mothers, who get together for a counselling session with one of the hospital’s health workers. A range of topics are covered, including food preparation, nutritional value of local produce, breastfeeding, and child development. In some cases, malnutrition in Bangladesh is not due simply to a lack of food, but due to lack of education or information as to how best to feed children. For many of these mothers, the sessions are the only source of reliable information when it comes to child care, and they are encouraged to share what they learn here with their family and friends when returning home.
Hasan smiling at the NRU ward after feeding and psycho-social stimulation.
Once Hasan achieves a 15% weight gain since admission, or his z-score improves to -2, he will be discharged from the Nutrition Rehabilitation Unit and his mother will be advised to come back for follow-up in a week. Follow-up sessions lasting up to a year are designed to prevent children from relapsing, monitor their ongoing well-being, and answer any questions the parents might have.
Thanks to the protocols developed through the organization’s research, the fight against SAM at the Dhaka Hospital ensures that all children have the opportunity to recover from SAM and go on to lead healthy and happy lives.
Sheema, is one of the hospital’s most memorable children who had SAM. She was admitted in critical condition with diarrhea, malnutrition, and pneumonia, and her successful recovery after 35 days of treatment at icddr,b has been used as a case study since.Read more