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GAVI senior program manager
A typical vaccination outreach session at a village maneaba. Kiribati is the smallest and most remote country to receive GAVI support. 103,000 people live across three islands. On May the 6, 2013, Kiribati launched the pneumococcal vaccine.Photo credit: GAVI/2013/Raj Kumar
With 103,000 people living across three islands, Kiribati is the smallest and most remote country to receive GAVI support. Its position close to the international dateline and the equator make the group of islands, spread across 3.5 million square kilometres, one of the most difficult to access by people or vaccines.
I was honoured to be the first GAVI staff member ever to visit this mesmerising country to participate in the launch of the Pneumococcal vaccine for the children of Kiribati.
More than half the population resides in the capital, Tarawa, which boasts just one road. There is no television or a regular newspaper – although a vernacular bulletin comes out once a month. Telephone and internet connectivity are challenging. Kiribati exists almost in a world of its own, unworried and untroubled by global security and economic issues.
The commitment to maternal and child health services in the country is amazing. Every child receives Pentavalent vaccine and vaccinators do not know of any child who has not received the vaccine. They can be sure because they know everyone, communities are like large families and everyone is on their minds. The society is egalitarian and hierarchy is not important.
The Pneumococcal vaccine launch event on 6 May was an impressive, traditional spectacle. Anybody and everybody who matters in the health sector were there. What was more impressive was that next day the vaccination was being done in three facilities I visited. The approach was simple. At Santo Ioane health centre, after vaccinating many children, two nurses Utinia Dennis and Lavender Tineon assisted by a Nurse aide Terengaoiti Toteri went to an outreach site two kilometres away and immunised more children, followed by house visits to ones who did not turn up.
The outreach sites are located at ‘maneabas’ (or meeting sites) which are the largest buildings in the villages and centre of village life, and the basis of island and national governance. Through this system, Pneumococcal vaccine was effectively rolled out all over Kiribati in just one week!
Next day we took a one hour boat ride to go to Abaokoro on other end of L-shaped island of Tarawa. The School Health Nurse Miriaa had completed the vaccination in the centre and had plans for rest of the week to cover four other locations to get to 57 children in her area. Every child had taken BCG and Hepatitis B vaccine at birth.
Equally interesting was that each of three centres we visited had new child cards and registers to record Pneumococcal vaccination. There were brand new posters with new schedule; all provided by LDS Charities, a faith based organization in Kiribati with a significant following. LDS is working closely with the Government to create an enabling environment and demand for vaccines across Kiribati - a good example of Government and CSO working together.
Does this mean Kiribati faces no challenges? No. The vaccine store is far from ideal. In the stores were three boxes of 1 ml. auto disable syringes and no one knew why they had been delivered to Kiribati. Also, according to GAVI’s eligibility threshold, Kiribati is no longer eligible for any new support as its per capita income is $2,030. However, the cost of living is high. So if one looks at PPP income, Kiribati drops more than ten places in the international economic rankings, below many other countries still eligible for GAVI support. This is a difficult situation. The Government can certainly sustain Pentavalent and Pneumococcal vaccines but other new vaccines would be a challenge, both in terms of financial resources and in-country technical expertise.
Towards end of my visit I felt in love with this new world, the like of which I never before encountered. For me, the smallest GAVI-eligible country is also one of the most fascinating. I am proud that the children of Kiribati are not being forgotten and will benefit from the power of vaccines.
Raj Kumar is a Senior Country Responsible Officer at the GAVI Alliance. AusAid is a major supporter of GAVI and its mission to immunise an additional 250 million children in developing countries by 2015, saving an estimated four million lives.
A volunteer checks the little finger of a child to see whether it has been immunised against polio, and administers a drop of oral polio vaccine while the child is still sitting in the traffic during an April 2008 immunization effort in India. Source: Rotary International/2008.
When the news came through in Andhra Pradesh that we had our first polio case for seven years, I was advising the state government on introducing hepatitis B and Japanese encephalitis vaccines.
Mainly affecting children under five, polio can lead to irreversible paralysis for about one in 200 infections. It can also lead to death if the paralysis interrupts the breathing.
Those who have lived and worked in less-developed countries are all too familiar with the terrible disability and deformation that polio leaves in its wake.
But, as with smallpox, polio is one of a handful of diseases that cannot survive for long outside the human body. And eradication is a real possibility.
When we have such effective vaccines, the single biggest obstacle to polio eradication is the strength of our immunisation systems. If the routine immunisation system is working, polio will not spread.
So while the child’s parents were willing him to survive and adjusting to the likelihood that survival would also mean permanent disability, I was fretting about our system. The next 30 cases highlighted weaknesses, but a well-aimed immunisation campaign finished off the outbreak.
A social health activist administers drops of the oral polio vaccine to a child in April 2008 during a door-to-door immunisation effort in India. Source: Rotary International/2008.
Around the world, high immunisation coverage with four doses of oral poliovirus (OPV) vaccine for infants has been key to polio eradication efforts. Indeed, enormous synergies exist between polio eradication and routine immunisation, because routine immunisation systems are still the most efficient and effective way of getting polio vaccination to where it’s needed most.
Persistent transmission in Pakistan and major outbreaks in Chad and the Democratic Republic of Congo reflect ongoing weaknesses in immunisation systems.
My country, India, is one of four countries in the world where polio is endemic, but since January 2011, it has not seen a single case of polio. This shows that eradication is possible.
Eradicating polio will be a tremendous demonstration of immunisation’s power, allowing countries like my own to focus on other life-saving vaccines.
Victory against polio will be triumph for us all.
Dr Raj Kumar is an Indian national. Between 2002 and 2006, he advised the state of Andhra Pradesh, population 75 million, on immunisation. Now as a Senior Programme Manager for GAVI, he manages GAVI’s portfolio in 13 countries across the Middle East and East Asia.
Raj KumarGAVI senior program manager, Afghanistan
My recent trip to Afghanistan is one of the most satisfying trips I have done for GAVI. Security remains difficult, but the sense of optimism is palpable. We’re supporting immunisation in Afghanistan, working with our partners in-country who are bursting with innovation and enthusiasm.
This exquisitely beautiful country introduced the pentavalent vaccine in 2009, protecting Afghan children against five deadly infectious diseases with a single course of three injections. This incredibly cost-effective vaccine literally saves tens of thousands of young Afghan lives every year. And because it’s a five-in-one vaccination, it saves on money, time and transport, too.
Now our colleagues in the health ministry are pressing to know more about the new pneumococcal and rotavirus vaccines that help protect against pneumonia and diarrhea, two of the world’s biggest killers of children. I’ve always gotten a buzz from working with immunisation, an incredibly simple technology at heart. The challenge is to save lives on an enormous scale in the most sustainable and cost-efficient manner.
There’s something even more special about doing it in a context of murderous instability. A previous visit in 2008 began with news of a suicide bomb that killed two of our colleagues from WHO. Conflict has been rumbling throughout this mountainous country for more than 30 years now.
No wonder its health system is such a wreck.
As in many other fragile states, though, Afghanistan’s NGOs do a fantastic job of providing basic health services to the population. That partly explains why some of Afghanistan’s basic health indicators have been improving rapidly.
Maternal mortality ratios have fallen by about a quarter in the past six years, and with immunisation coverage rates doubling in the previous decade, we will soon see large reductions in child mortality, too.
Afghanistan is still one of the world’s poorest countries, likely to remain heavily dependent on external donors for quite a while to come. But with GAVI helping protect young children from vaccine-preventable diseases, I'm also optimistic for the future.
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