RotaFlash, April 2016
Vaccines against diarrheal disease still have an enormous amount of untapped potential for Africa—for children’s lives, their ability to flourish, their families’ livelihoods, and their countries’ economies.
The Ministerial Conference on Immunization in Africa is currently underway. Leaders from across the continent have gathered in Addis Ababa, Ethiopia, to discuss how to achieve universal immunization coverage in all African countries and, in doing so, avert vaccine-preventable deaths and disabling diseases from limiting the potential of African children.
To help country decision-makers determine the best use of limited resources, Atherly’s team at PATH evaluates the costs and public health impacts of vaccines.
As with all public health decisions, the cost of immunization programs is an important consideration. Public officials have an important responsibility to spend public funds in a way that benefits the highest number of people. We already know that vaccines in general are one of the best buysin global health, and vaccines against diarrheal disease, which is responsible for 12 percent of deaths of African children under five years old, are no exception.
The financial burden of diarrhea
Diarrhea imposes a large public health burden—not just in terms of death and illness, but also in terms of finances. When a young child in a developing country gets sick with diarrhea, his or her parents usually have to pay for the care, which can amount to a significant portion of the family’s income. Additionally, because the parents have to stay home and take care of their child, or take him or her to a hospital, they lose wages that they would have otherwise made at their jobs. And then—on top of all that—often when one child gets sick, the infection is passed on to other children in the family. Having multiple sick children in the same household can be financially devastating for a family.
But what we also have to understand about diarrhea is that, when a child has multiple episodes of diarrhea, he or she is left more vulnerable to other infections, malnutrition, and stunting, which can have a lifelong toll on that child’s ability to grow, thrive, and contribute to society.
That is why we have to prioritize vaccines against diarrheal disease.
The promise of vaccines
Vaccines against rotavirus, the leading cause of severe and deadly diarrhea among children under five years of age, have now been introduced in 33 countries in Africa—27 of which are Gavi-eligible—and have a wealth of evidence on both their projected and real-world impact.
In 2012, I published an article on the projected health and economic impact of rotavirus vaccines in 72 countries eligible for support from Gavi, the Vaccine Alliance. Our model told us that, indeed, rotavirus vaccination would be considered very cost-effective in all of these Gavi-eligible countries—especially those in Africa, the region with the highest burden of diarrheal disease. Four years later, we are starting to see our projections come to life. In Rwanda, a recent study just revealed a 50 percent decline of all-cause childhood diarrheal hospitalizations following the introduction of rotavirus vaccines. And in Malawi, hospital admissions for diarrhea declined by 43 percent after the rotavirus vaccine rollout.
Additionally, vaccines against two of the other leading causes of severe diarrhea—enterotoxigenic E. coli (ETEC) and Shigella bacteria—are currently under development. While a lot more research will be needed before they can be introduced in countries, early estimates indicate the vaccines would be highly cost-effective in low-resource settings. We hope this evidence will help decision-makers as they consider and potentially plan for ETEC and Shigella vaccine introduction in years to come.
Saving lives, saving costs
We cannot afford to let any more children miss out on the protection of lifesaving, life-improving, and highly cost-effective vaccines against diarrheal disease. Diarrhea caused by rotavirus alone costs the lives, livelihoods, hopes, dreams, and futures of hundreds of thousands of children across Africa every year. For their families, the impact of rotavirus vaccination programs means more than just economics.
As countries with rotavirus vaccination programs have already shown, it means that more children can live past their fifth birthday. It means more children who are able to live to the full extent of their potential, not held back by disability, stunting, long-term illness and expensive hospital visits, or early death caused by rotavirus diarrhea. It means more parents are better able to take care of their children, work productively, and contribute to growing economies.
The cost of not introducing vaccines against diarrheal disease is just too high. By prioritizing vaccines against diarrheal disease, leaders across Africa can help ensure that African children and their families not only survive, but thrive—both physically and financially.
Photo credit: PATH/Gabe Bienczycki.Read more
Let’s face it, after more than eight years leading PATH’s work on developing vaccines against Shigella and enterotoxigenic Escherichia coli (ETEC) and more than three decades of working on enteric diseases, you might assume that I’ve heard it all when it comes to diarrhea. Not in the least!
There have been some amazing advances in the enteric vaccine field over the last few years, and I’m sure there are lots more that I don’t even know about. That’s why I’m so excited to announce PATH’s first international Vaccines Against Shigella and ETEC (VASE) Conference. We’re launching this new biennial conference series in Washington, DC on June 28 to 30, 2016, and we want you to be there.
I know what you’re thinking – why should I come to yet another dry scientific meeting? Well, this is where we’re hoping that VASE will break the mold. We’re taking a unique approach to the typical vaccine conference. We want to bring together a diverse group of scientists, public health professionals, immunization leaders, vaccine industry representatives, international donors, and other experts to engage in collaborative discussions focused on making Shigella and ETEC vaccines a reality for children in the developing world.
Truly making these vaccines a reality for these kids is the key. Although we expect to include plenty of updates on vaccine research, burden of disease, and other typical scientific topics, we’re aiming for every presentation, session, and discussion to include a link back to this important end-goal. (If you have a presentation idea, I urge you to submit an abstract – deadline for submission is March 1, 2016.)
We’re also reaching far and wide to bring together a diverse group of participants from across the globe. We aren’t charging a registration fee to make it easier for anyone to attend (registration opened on February 15 – sign up now!), and we’re offering the opportunity to apply for a travel grant (deadline for applications is May 1, 2016) if you need help getting here. We really want to get voices from the front lines of the war against diarrhea in the room for these discussions, since they’re the ones who can best help us figure out how to get these new vaccines to the kids who need them most.
Finally, we’re designing a conference program that has lots of opportunity for interactive discussion, including some focused small-group workshops to really zero-in the challenges and potential solutions to making new enteric vaccines a reality.
One last point: while the primary focus of the conference is on Shigella and ETEC, we recognize that there are many other neglected enteric diseases emerging as important causes of illness and death among infants and children in the developing world. For this reason, we are also hoping to include broader work on these and other pathogens in the conference program.
I hope to see you at VASE 2016!
Photo credit: PATH/Richard Walker.Read more
Let’s be honest. As someone who has worked in child health for many years, I have a particular passion for diarrhea. One of the leading killers of children, but so very preventable and treatable, diarrhea is often on the top of my mind. It doesn’t take much for me to bring up diarrhea at the dinner table. Want to talk stools over Thanksgiving turkey? No problem!
However, even I have been surprised at just how often I can talk about poop now that I have a six-month-old son. My passion for poo has gone well beyond “professional” advocacy to ensure that children around the world are no longer dying from dehydration caused by diarrhea. I literally start wondering about poop from the minute I wake up. My son’s dirty diapers, to be exact. Little did I know just how much you can determine from a baby’s dirty diaper. The pediatrician will ask about how often the baby poops. I ask his daycare providers how often they change his diapers (and if they were wet or dirty. Or both!). My husband and I can spend an entire dinner conversation talking about the frequency and consistency of bowel movements. I am also keenly aware that without access to diapers and wipes, clean water, and an easy way to dispose of the mess, this would be an entirely different conversation. I may talk about poop a lot, but it’s (mostly) thankfully contained to the diaper!
Despite my ongoing (and increasing!) focus on poop, one thing remains: entirely too many children continue to die from diarrhea. Clean water and access to improved sanitation are woefully lacking in too many communities around the world. Caregivers often assume diarrhea is a “normal” part of being a baby or young child and as a result seek treatment too late or treat it inappropriately. Only 35% of children receive oral rehydration salts (ORS) when they present with diarrhea. The number of children who receive zinc, a proven supplement that helps to shorten the duration of diarrhea and prevent future episodes, is even lower. The number of children still (inappropriately) receiving antibiotics for diarrhea boggles the mind.
As we all charge into the post-2015 era, I worry that my fixation on diarrhea – and child health more broadly – isn’t felt by the decision makers and policy makers in the countries where we work. I am eternally grateful that my son has access to clean water and, when he’s ready, a flushable toilet. The pediatrician is a call away, and I can easily access treatment at any number of pharmacies. But we must make this a reality for children the world round. We have no more excuses: we know what works, and we know how to save lives. We need to elevate the dangers of diarrhea – and the importance of child health – to ensure that policies allow for appropriate treatment, health providers are adequately trained, caregivers know where to access ORS and zinc, clean water is available, and that the health of each and every child is taken as seriously as I take my son’s diapers. I joke about my obsession with poop, but ending preventable child deaths really is no laughing matter.Read more
Dr. Rajiv Tandon, Senior Technical Advisor for Maternal, Newborn, and Child Health and Nutrition based in PATH’s New Delhi office and long-time advocate of public health and nutrition, will be speaking at the 53rd Annual Conference of Indian Academy of Pediatrics (PEDICON) this week in Hyderabad. At his remarks during PEDICON, he will speak to those factors (such as socioeconomic issues) that interfere with children thriving in low-resource countries.
A pediatrician who has significant experience in supporting the Government of India systems and programs— such as the national five-year plans, the Reproductive and Child Health Programme of the Ministry of Health and Family Welfare, the National Health Mission, and the Integrated Child Development Services of the Ministry of Women and Child Development, and the Coalition for Sustainable Nutrition Security in India—Dr. Tandon also points out that India today has the dual burden of malnutrition due to lack of access to nutrients and to unhealthy eating habits, which are now leading to non-communicable diseases.
Detailing the South Asian enigma around the high incidence of low-birth-weight infants and intergenerational cycle of malnutrition, he highlights the task that India still faces. The high prevalence of gastroenteritis in India, which exacerbates malnutrition, remains due to social cultural practices and geographies like rapid urbanization that create a different set of public health and nutrition-related issues in the rural and urban poor environments.
Apart from this is the diversity of religion, caste, tribe, language, and dialect, all of which makes addressing social and behavioral changes extremely contextual and difficult to achieve through a one-size-fits all approach. All of this also contributes to the need to look into in-country migration, inequity, governance, and gender dimensions.
Malnutrition and diarrheal disease go hand in hand. Underscoring the lack of appropriate public health systems, Dr. Tandon emphasizes the importance of continuing to prevent and treat diarrheal disease using proven interventions like ORS and zinc, proper handwashing with soap and water, vaccines, and better sanitation facilities.
Speaking about the diarrheal disease burden in India and the progress that has been made in reducing the incidence over the past four decades, he applauds the Government of India’s decision to introduce the easy to administer oral rotavirus vaccine in the Universal Immunization Programme in four of 36 States in February 2016.
Photo credit: Marc Koska.Read more
I know of at least two toilet museums (a toilet shaped one in South Korea and Sulabh International Museum of Toilets in India). It would be great if, like many museums, they were just documenting the history of a problem that was solved long ago. But the world missed the global sanitation targets under the Millennium Development Goals.
In my role at Improve International, I often feel like a Negative Nelly, because I highlight the challenges faced by the water and sanitation sector. So at the beginning of this new year (at least for this blog), I will try being a Positive Polly. It’s good timing, as 2016 is also the year we embark on the journey to Sustainable Development Goal 6, “Ensure access to water and sanitation for all.”
For a recent research project for CRS, I felt like an archaeologist, trying to dig up evidence of long-term sanitation successes. Based on what we found, I believe universal sanitation is achievable.
Depending on where you live, you might be experiencing 100% national coverage right in your own house. (Full disclosure: I live in the US and I have one toilet in my home. TMI: It isn’t always as clean as it should be.) If you live in the US, have you been anywhere lately (besides Manhattan) where you couldn’t easily find a toilet, and handwashing facilities? So how did that happen? Governments of developing countries who still have a way to go toward universal coverage and NGOs who work there can learn from the successes of other countries.
Examples of sanitation achievements that are well documented include Bangladesh, Brazil, Malaysia, Singapore, South Korea, and Thailand. While some consider these countries to be more developed, the gross domestic products (GDP) per capita in 1960 for Bangladesh, South Korea, and Thailand, for example, were lower than those of Ghana, Liberia, Senegal, Zambia, and Zimbabwe. Singapore seems like a totally modern city now, but in the 1960s, it was a “polluted, congested city where open defecation was rampant.”
Examples of GDP and national improved sanitation coverage trajectories 
And while the lowest levels of sanitation coverage are found in the least developed countries, particularly those in sub-Saharan Africa, Ethiopia kicked butt. They achieved the largest decrease in the proportion of the population practicing open defecation (from 92% in 1990 to 29% in 2015).
From these countries we can see that universal sanitation starts with political will and leadership, along with adequate funding, cooperation and coordination, affordable technology, and development of sustained local capacity. We are also starting to accept that a long-term drive (i.e., decades) toward a cultural shift is required to raise awareness and change behavior. These are things that are difficult to do (especially for project-oriented NGOs) and harder to measure. But we need to get past the “Build more cheap latrines!” mentality. Sanitation does not solely refer to containment of feces. Toilets are only one element in an entire sanitation system, which should include collection, transport, treatment, and use of excreta. And a crappy toilet (literally or figuratively – i.e., low quality) can be worse than no toilet at all.
Before and after latrines in a suburb of Blantyre, Malawi.
What can you do to help the countries that are already “there” and those that aren’t there yet? If you work for an NGO, your organization could help promote:
- Consideration of menstrual hygiene
- Promotion of hygienic use of toilets, especially with access to water for cleaning and handwashing
- Helping to link users with finances and services for pit emptying or building new latrines, as well as upgrading their services
- Help communities with animal excreta management, solid waste management, and managing young children’s feces.
It feels good to be optimistic, but realistic. We need to learn from the past, question the build on the good, and resolve the bad. Join me soon after 2030 at the “Museum of How We Got to Universal Sanitation.” I hear they’ll have a great coffee shop.
Bangladesh: Sustainability and equity aspects of total sanitation programmes: A study of recent WaterAid-supported programmes in Bangladesh, Community-Led Total Sanitation in Rural Areas: An Approach That Works, Lessons Learned from Bangladesh, India, and Pakistan: Scaling-Up Rural Sanitation in South Asia, Community Led Total Sanitation in Bangladesh: Chronicles of a Peoples Movement, Citizen's report on sanitation
Brazil: Community-driven sanitation improvement in deprived urban neighbourhoods, Low-cost Sanitation Improvements in Poor Communities: Conditions for Physical Sustainability, The Experience of Condominial Water and Sewerage Systems in Brazil: Case Studies from Brasilia, Salvador and Parauapebas
Singapore: Successful Sanitation Projects in Thailand, Malaysia, and Singapore, Achieving total sanitation and hygiene coverage within a generation – lessons from East Asia, 50 years of sanitation in Singapore
Thailand: Achieving total sanitation and hygiene coverage within a generation – lessons from East Asia; Successful Sanitation Projects in Thailand, Malaysia, and Singapore, Evaluating the effectiveness of public finance for household sanitation in rural Thailand, Universal Sanitation – Thailand Experiences
United States: The Sanitary City: Environmental Services in Urban America from Colonial Times to the Present, City Water, City Life: Water and the Infrastructure of Ideas in Urbanizing Philadelphia, Boston, and Chicago, The Cholera Years
World: The Big Necessity
 Table adapted from Northover, H., Ryu, S., & Brewer, T., 2015. Achieving total sanitation and hygiene coverage within a generation – lessons from East Asia. London: WaterAid.
 World Bank Data 1960 GDP per capita, data for Bangladesh, Brazil, Malaysia, Singapore, South Korea, Thailand (accessed January 6, 2016)
 World Bank Data Improved sanitation facilities (% of population with access) 1986-1990
 World Bank Data Improved sanitation facilities (% of population with access) 1996-2000
 World Bank Data Improved sanitation facilities (% of population with access) 2011-2015
Photo credits: Susan Davis.