• Global sustainability

    Talking about the road to self-sufficiency with Sri Lanka, Honduras and Angola

    Representatives of three health ministries share their hard-won insights into what it takes to transition out of Gavi support.

    At the start of 2016, four countries transitioned out of Gavi support. For each of these countries, this historic milestone marked the end of the long road to fully self-financing their vaccines and sustaining their own immunisation programmes. But it also signalled the beginning of another, even tougher journey for our Alliance.

    With 20 countries set to transition by 2020, the Gavi business model now faces the biggest test in its history.

    The achievements of Bhutan, Honduras, Mongolia and Sri Lanka demonstrate the model does work as long as countries plan early, harness political will effectively and work closely with Gavi from the very start. But some countries that are set to transition, like Angola, are facing considerable challenges. For countries like these, the expert guidance that Gavi offers is especially important.

    We invited Dr Yolani Batres, Secretary of State at Honduras’s Bureau of Health, Dr Deepa Gamage, Consultant Medical Epidemiologist at the Sri Lankan Ministry of Health, and the Angolan Health Minister, Dr Luis Sambo, to share their insights into the challenges that countries will face along the road to transition in the coming years.

    • Dr Yolani Batres
      Bureau of Health, Honduras

    • Dr Deepa Gamage
      Ministry of Health, Sri Lanka

    • Dr Luis Sambo
      Minster of Health, Angola

    Drs Batres and Gamage, could you tell us how Honduras and Sri Lanka fared in their first year as transitioned countries?

    Dr Yolani Batres: 2016 was a very good year for vaccination in Honduras. Coverage was above 95%, even in municipalities that had declining rates in 2015. We paid for 99% of vaccines out of our own budget. Gavi financed the introduction of inactivated polio vaccine (IPV) and 50% of the cost of introducing human papillomavirus (HPV) vaccine. In 2017, we will fund the addition of the human papillomavirus vaccine 100%. Last year, PAHO also confirmed that we had eliminated measles.

    Dr Deepa Gamage: Sri Lanka was in a good position at the end of 2016. We weren’t facing any special challenges. Apart from the pentavalent vaccine, we purchased all vaccines ourselves.

    Dr Sambo, where was Angola in the transitioning process?

    Dr Luis Sambo: Angola was in the accelerated transition phase – the final phase before transitioning out of Gavi support in 2018. We faced a number of challenges. Oil prices had fallen, which reduced the national income and the amount of public funds available. Despite this, we had to finance the introduction of new vaccines, strengthen human resources and manage immunisation more efficiently. The yellow fever epidemic affected our progress but, because we’d begun preparing to transition as far back as 2013, it hasn’t slowed our momentum down too much.

    Dr Sambo, you paid off all of Angola’s co-financing arrears for 2015 as well as paying in advance for 2016 and 2017. Why?

    LS: Because I know that immunisation is a cost-effective public health intervention that’s easy to administer. I see it as the spearhead for expanding our entire public health network and increasing the number of health service delivery points.

    What were or are the most significant immunisation challenges for your countries?

    YB: For us, it was achieving and maintaining the highest possible level of coverage. We also had to negotiate with Gavi to maintain our current level of vaccine prices and have the possibility to introduce new vaccines with Alliance support. We overcame these challenges by working hard, in partnership with Gavi.

    DG: To be honest, we didn’t face any significant challenges. There was no large-scale reluctance on the part of the population to be immunised. We continued to develop new cold chain technologies.

    LS: We carried on with our work of strengthening the Angolan immunisation system and putting health reform in place. Among other things, this will guarantee that vaccines and other essential supplies are financed, improve our integrated logistics system and strengthen data capture and quality. We’re opening new health posts across the country and I’d like every health post in Angola to be able to deliver immunisation services, with all health personnel trained to carry out vaccination.

    How did Gavi help you overcome these challenges?

    DG: Gavi covered 50% of the cost of introducing the HPV vaccine in 2016 and provided a vaccine introduction grant. To make sure that IPV supplies continued in the face of supply scarcity, Gavi helped us to introduce fractional dosing.

    YB: Honduras passed a law in 2013 that guarantees free vaccines for the whole population and sufficient funds to sustain vaccine procurement. Gavi helped us draft the legislation and provided excellent technical support. This law is key to our work today.

    LS: Apart from offering advice and guidance, the Gavi health system strengthening grant is helping us to grow our network of fixed vaccination posts, replace obsolete equipment and acquire cold rooms and continuous temperature control systems. It’s also supporting the training of mid-level managers and front-line health staff. We’ve also been able to increase the number of transport vehicles in our fleet. The grant is helping us improve data quality and use.

    What advice would you give countries transitioning out of Gavi support?

    LS: I would say that countries should take responsibility for funding immunisation sustainably, despite the competing priorities of other health programmes. They should also address the gaps in Gavi support using national resources and those of other partners.

    YB: Work as a team with Gavi. Don’t attempt to do everything by yourselves. In the lead-up to transition, the Gavi technical team came to Honduras and we sat down and planned together. Gavi showed us the reality of our situation and what our needs genuinely were. In our experience, when a country is transitioning it’s essential to administer funds correctly and have the right kind of technical support. This is what Gavi offered us and it was invaluable.

    DG: Sri Lanka has always been determined to maintain ownership of our national immunisation programme and avoid being too dependent on support from outside the country, although we’ve accepted this when necessary. I would recommend that countries take decisions based on country-specific evidence.

    What does the immediate future look like for your country and for immunisation, and what is Gavi’s role?

    DG: We’ll continue to sustain the high levels of coverage and equity we’ve achieved for immunisation. At the same time, we’ll be implementing the introduction of the HPV vaccine.

    YB: Our immunisation programme has credibility with the Honduran people because it’s very effective. We have the budget to maintain the vaccines in the programme. But we always want to have a window of access to new vaccines in the future. For example, for Zika and malaria, which are doing a lot of damage in Honduras. Being partners with Gavi will enable us to buy new vaccines.

    One of the things I appreciate most about Gavi is their willingness to listen to the views of developing countries. It’s not just about us receiving funds. And, with its fragility policy – especially in developing countries – Gavi is constructing a new agenda that gives us lots of hope for the future. Really, the relationship between Honduras and Gavi couldn’t be better.

    LS: Our immediate priorities are nancing immunisation for long-term sustainability and strengthening health teams across the entire country. This is challenging, when you consider our financial crisis and shortages in the health budget. Gavi is monitoring our progress towards transition and making sure what we do is in line with what we actually should be doing.

    We’ll continue to work with Gavi to identify what it will take to keep our immunisation programme sustainable post-transition. Whatever happens, we have the political will to do everything we can to increase and sustain coverage and equity in Angola.

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    Global markets

    When disrupting markets becomes a force for good

    The disruption of failing markets can challenge old assumptions and cast light on new solutions.

    Gavi was created in order to overcome a seemingly intractable problem: how best to address market failures that had led to stagnating global immunisation rates. Since inception, Gavi and its public and private sector partners have succeeded in dramatically reducing the price of several vaccines and have created a more sustainable supply for developing countries.

    In 2016 Gavi began applying the same approach to immunisation delivery systems. We started by launching the cold chain equipment optimisation platform (CCEOP), which is aimed at stimulating the development and production of innovative cold chain equipment for developing countries. We haven’t stopped there.

    With our 2020 goals at the forefront of our thinking, the Alliance is directing its disruptive influence to new markets. In the past 12 months, we have forged partnerships with businesses, both large and small. Each supports a range of innovative products, from drones to data-aggregation devices, which have the potential to break critical barriers to universal immunisation coverage.

    1. Driving up demand

    Promoting the benefits of immunisation encourages parents to bring their children for vaccination. Gavi is partnering with corporations and foundations committed to using their expertise in social marketing to drive demand for immunisation in frontiera and emerging markets.

    Unilever and Gavi, for example, have partnered to jointly promote immunisation and handwashing with soap – two of the most cost- effective ways to prevent diarrhoea and pneumonia. Building on Unilever’s experience with Lifebuoy soap, the project will use 21st century tools to boost immunisation coverage and save children’s lives.

    Highlighting the value of vaccines can also leverage markets for products and services outside the health sector, in education in particular. Recognising the strong correlation between low immunisation rates and access to education, we have started a partnership with Qatar’s Education Above All Foundation (EAA). Gavi will draw on existing EAA resources and partners across Asia and Africa to help communities with poor school attendance and low immunisation rates.

    This initiative is the first of its kind and directly supports two of the United Nations sustainable development goals (SDGs): ensuring healthier lives (SDG 3) and promoting more equitable education (SDG 4). It is also an example of SDG 17, which emphasises the need for cross-sector partnerships to achieve sustainable development.

    2. Creating a market for innovation

    One of the biggest challenges facing immunisation delivery systems in developing countries is poor infrastructure. The supply chain that delivers vaccines from central repositories to primary healthcare clinics still relies on fridges, generators and other technology that has often not been updated in decades. This can slow down or even stop the delivery of life-saving vaccines. While there are many potential solutions, these frequently lack the right market conditions for scale up. Businesses that have developed a new technology struggle to secure the necessary funding to take it further, while governments find it difficult to select the most appropriate, cost-effective option.

    In 2016, Gavi sought to address this failure of current markets with a new platform called Innovation for Uptake, Scale and Equity in Immunisation, or INFUSE for short.

    Launched at the 2016 World Economic Forum meeting in Davos, INFUSE identifies tried and tested innovations that have the potential to improve vaccine delivery in developing countries. It then “infuses” them with capital and expertise to help take them to scale in Gavi countries – creating a new marketplace for innovative solutions within the countries that need them most.

    In its inaugural year, a high-level review panel, composed of corporate leaders, technology pioneers, investors and global immunisation specialists, selected seven of the most promising innovations. Gavi will help accelerate their adoption in developing and emerging markets.

    All the 2016 “Pacesetters” will improve data availability, quality and usage. If brought to scale, each will dramatically impact vaccine delivery.

    3. Breaking into new markets

    In a drive to open up new markets, Gavi has been working closely with governments, companies and organisations based in the Middle East and China.

    In the wake of a financial contribution from Saudi-based Alwaleed Philanthropies (AP), Gavi has expanded its presence in the Middle East. In 2016, AP committed more than US$ 1 million – which was doubled by the Bill & Melinda Gates Foundation – to help finance immunisation programmes throughout Gavi’s 2016–2020 strategic period. Gavi-supported programmes are among thousands of projects in over 90 countries that AP has supported in the past 35 years.

    a – A frontier market is a type of developing country which is more developed than the least developing countries, but too small to be generally considered an emerging market.

  •  
    Global markets

    Leapfrogging the 'last mile' in delivery systems

    In Rwanda, the long rainy season frequently washes away vast tracts of road, depriving remote health centres of life-saving vaccines and other critical medical supplies. ln extreme medical emergencies where time is of the essence, the lack of basic medicines and blood for transfusion can make the difference between life and death. This state of affairs is common throughout the developing world, where more often than not it is the very last bit of the journey to the health clinic that is the most difficult and arduous of all.

    To overcome these obstacles and leapfrog the “last mile” in the supply chain, the Rwandan Government has turned to cutting-edge drone technology, pioneered by the California-based robotics company, Zipline. Zipline is transporting emergency blood supplies to women suffering from postpartum haemorrhage. The new service is expected to cut average delivery times from hours to minutes.

    Gavi laid the foundations for this partnership, both by easing government concerns about working with the private sector and by securing funding from the United Parcel Service (UPS) Foundation. UPS provided a US$ 1.1 million set-up grant and logistics expertise in order to support Zipline’s deployment to Rwanda. In collaboration with the Government, Gavi is now exploring the potential for using Zipline drones to carry vaccines.

    This initiative demonstrates how our Alliance can apply private sector innovation and expertise to improve immunisation delivery. By calling on UPS’s logistics expertise, the Rwandan Government’s leadership and Zipline’s cutting-edge technology, Gavi may have found a way to cut out the last difficult step of the supply chain, that critical last mile. Transforming the marketplace for delivery of medical supplies could hold the key to reaching every child.

  • Global equality

    Collaboration in the community helps prevent cervical cancer

    Routine immunisation with the HPV vaccine protects the health of women and girls.

    Infectious diseases do not always affect men and women equally. One virus in particular has a disproportionate impact on the health of the world’s women and girls – the human papillomavirus (HPV).

    Although this virus infects both men and women, it is women who suffer the most severe consequences. HPV is the primary cause of cervical cancer, which currently kills 266,000 women every year. However, death rates are increasing, and if left unchecked, cervical cancer is in danger of claiming more lives than childbirth.

    The great majority of sufferers (85%) live in low-income countries where access to screening and treatment is limited. Such high levels of female morbidity and mortality debilitate entire communities, depriving children of their mothers and families of their primary caregivers.

    “These women die on their own – that is the reality,” says Professor Mamadou Diop, oncologist and head of Dakar’s Institut Curie in Senegal, which has the world’s 15th highest incidence of cervical cancer. “These are really very active women, who have children to raise, homes to run and are pillars of their family and community.”

    Up to 90% of all cervical cancer cases can be prevented by the HPV vaccine which is given to girls between the ages of 8 and 14 years. However, reaching this target population with vaccines in developing countries is not easy. Adolescent girls are not usually served by existing health services and not all go to school. On top of which many women, and in some areas whole communities, are unaware of the importance of the HPV vaccine.

    In the face of these obstacles to uptake, high levels of communication and collaboration from every sector and corner of the community are essential to fulfilling the vaccine’s cancer-preventing promise.

    When Gavi approved Senegal’s HPV vaccine demonstration project in 2014, the health and education ministries joined forces to raise awareness of cervical cancer, the vaccine and its benefits among a range of audiences. In Dakar Ouest and rural Méckhé 100 km away – the two districts targeted by the demonstration project – school teachers were trained alongside health workers.

    “We did a lot of communication even before the project started,” says Mame Parie Diop, health education supervisor at Méckhé’s health centre. “We gathered local religious leaders to explain the HPV vaccine demonstration project, but to also educate them about the illness and the importance of preventing it.” The project launch itself was turned into an exercise in communication and trust-building, with the daughters of doctors, nurses, teachers, as well as religious and community leaders receiving their shots in front of the rest of the district.

    There was no let up even after the project started. With health ministry support, messages were relayed via community leaders, two local radio channels and television, posters and T-shirts. In many communities, sexually transmitted disease can be a sensitive subject, which is why communicating rst and foremost that the HPV vaccine prevents cancer was key. “Communication was a challenge, so we had to anticipate and stop rumours before they started,” adds Mame.

    Critically for the programme, this information was also carried by individuals such as Oumi Thioune, headmistress of Elhadji Ndiayar Ndiaye Elementary School in Méckhé. Her reasons for getting involved were clear. “Every Senegalese woman knows how serious cervical cancer is. Everyone has heard about it,” she says.

    In each French-speaking or religious school (Daara), a specially trained teacher explained the vaccine’s benefits to other teachers, parents and students. Often this teacher counted the number of girls eligible for the HPV vaccine, and ensured that they received their shot on immunisation day. “Once we were informed by the doctor and his local team, we got parents involved, we raised awareness, we counted up the girls of the right age,” says Oumi. “And for each dose, I looked after the girls.”

    Senegal’s information campaign also targeted the wider community, with local advocates and religious leaders enlisted to help identify all girls eligible for the HPV vaccine. This was especially important in rural Méckhé, where a large proportion of girls do not go to school.

    Community networks helped health workers nd girls at risk of missing their vital second dose of HPV vaccine. “We did our best to get everyone on board with the vaccine, and it worked,” says Ibrahima Mbaye, manager of the Expanded Programme for Immunization (EPI) in Méckhé.

    In the urban district of Dakar Ouest, Dioma Mbengue is a nurse and head of vaccinations at the Philippe Senghor Health Centre. She played a vital role in communicating with the girls’ parents, helping them understand what was at stake. “We explained to parents that it’s a vaccine that prevents cervical cancer, a very dangerous disease,” she says. “Parents accepted it. If you talk about cervical cancer, people are afraid.”

    There are reasons to be afraid. Many women struggle to afford treatments for cervical cancer and turn to ineffective traditional medicines instead, explains Professor Diop from his Dakar clinic. “This cancer can be prevented through vaccination and screening. For me, it has to be a national priority,” he says.

    Disappointingly, to date few countries have made the step up from running a demonstration project to a national HPV vaccine introduction. With the 2020 global target of vaccinating 30 million girls against HPV infection in jeopardy, in 2016 Gavi took steps to encourage more governments to add HPV immunisation to their routine programmes.

    Following a recommendation by WHO’s Strategic Advisory Group of Experts (SAGE) on immunisation, Gavi no longer requires countries to run demonstration projects before applying for support for national introductions. Gavi will also fund the vaccination of multiple age cohorts of girls, aged 8 to 14 years, allowing HPV vaccine programmes to reach greater numbers more quickly.

    “Vaccination is so important, we wish the vaccine could be available for every woman in Senegal, every woman in the world,” says headmistress Oumi Thioune.

    With plans for a national introduction by the end of 2017, other countries would do well to learn from Senegal’s experience and ensure the HPV vaccine gains the publicity it deserves. Thanks to the work of Dioma, Oumi, Mame and others like them, more and more Senegalese are now demanding the vaccine to protect their young girls from a cancer that could blight their futures. For Méckhé EPI manager Ibrahima Mbaye, it’s not just about creating a healthier society. It’s a matter of protecting loved ones. “We’re proud that it’s our families, sisters and nieces who are benefiting,” he says, “It’s deeply personal.”

  • Global equality

    Pioneering integrated healthcare in Togo

    Togo is using immunisation with the HPV vaccine to deliver integrated healthcare to young girls – care that may just improve their life chances.

    Globally, immunisation programmes reach an estimated 100 million people each year – more than any other single intervention delivered through national health systems.

    In many low-income countries, delivering the HPV vaccine to young adolescent girls represents a unique opportunity to deliver valuable lessons in healthcare – both to prevent the spread of HPV and to provide protection from other infectious diseases.

    Over the past two years, Togo has conducted HPV vaccine demonstration projects, running pilot schemes in two districts with guidance from Gavi partners, notably the United Nations Population Fund (UNFPA), UNICEF and WHO. In partnership with the education ministry, vaccinators not only immunised girls against cervical cancer but also worked hand-in- hand with teachers to educate adolescents about their health. For an hour before receiving shots of the HPV vaccine, girls were taught about puberty, menstrual health and the importance of handwashing.

    As the pilot health education efforts progressed, Togo and its Gavi partners learnt their own lessons about the best way to deliver HPV vaccine and other adolescent health services nationally. “It’s an excellent case study,” says Danielle Engel, adolescent health specialist at UNFPA. “It showcases how the support of partners can be instrumental in implementing projects like these. It also shows that if you take the right decisions at the right time, you really can help a country into integration mode.”

    Togo is now working to create tailored educational programmes utilising materials developed and tested in neighbouring countries. “We would like to see girls, and boys, be the agents of their own health, not just recipients of key messages,” says Danielle.

    With this west African country of 7 million people planning to roll out the HPV vaccine nationally, the next challenge will be converting these early successes into a sustainable model for treating 300,000 adolescents each year. If successful, Togo will become an exemplar of how to use immunisation programmes to deliver integrated health services to traditionally under-served demographic groups.

  • Global coverage & equity

    The missing

    Advances in data collection, technology and training are needed to ensure more children gain access to vaccines.

    Finding a single missing child can be difficult. So imagine finding millions of missing children, especially when no formal record shows they even exist. This is the challenge Gavi now faces if it is to continue improving access to vaccinations for the world’s poorest infants and young people.

    Since 2000, when our Alliance was created, basic immunisation coverage has steadily increased. Nevertheless, large pockets of low coverage persist in hard-to-reach communities, often masked by high national averages. Until we address how to find these people and reach them with life-saving vaccines, there is a risk that not only will progress stagnate but inequities in immunisation will continue to widen.

    That is why data is a major focus for Gavi in this strategic period. To improve both average coverage and equity in immunisation, we need accurate, real-time data on the number of vaccines shipped, stored and administered. We also need to keep better records of where people live, and at the most basic level, to ensure that formal records exist for every child born.

    Globally, one in three births is not registered. Without a birth certificate, children risk being overlooked by authorities, missing out on their right to vital health and education services. Left vulnerable to infectious diseases and neglect, the impact on their lives can be lasting and lead to disenfranchisement.

    Some of the least acknowledged and hardest-to-reach children live in remote, rural settings. However, just as many “missing” vulnerable children reside in the world’s ever-swelling urban slums where they too go unnoticed and unvaccinated. More than ever before, we need reliable data on who they are, where they live, and what healthcare they need.

    With 86% of all children now receiving a full course of basic vaccines, our Alliance is already finding ways to reach many of the “missing millions”.

    By making the best use of modern technology, our efforts to support immunisation are starting to fill the gaps. It’s no coincidence that considerably more children now have a vaccination card than a legal form of identity.

    In recent years, several countries have adopted a range of innovative approaches to better capture critical immunisation data. These have involved the use of mobile phones to log the movement and management of vaccines through the cold chain, and the analysis of geospatial satellite data to map missing communities. Pakistan’s experience in particular demonstrates how efficient monitoring and surveillance systems can bridge gaps in equity, significantly increasing immunisation coverage.

    However, information needs to ow both ways. We need to innovate to improve the collection of immunisation-related information and we need to find new ways to tell people about the benefits of vaccination. Often individuals, families or even whole communities are unaware of the positive impact of vaccines. It is this group that we need to target if we wish to increase demand for immunisation and related health services.

    Throughout 2016, Gavi has been supporting efforts to do just that. U-Report is an automated text-based chatbot app developed by UNICEF for mobile phones which collects community feedback about vaccination campaigns. According to data collected by the U-Report app, use of this technology helped to increase turnout at vaccination clinics in Cameroon by 20%.

    U-Report data also revealed that more than half of people surveyed in Cameroon heard about vaccination campaigns through community mobilisers, people who are tasked with promoting the benefits of vaccines within their local neighbourhood. This compares with just 5% who reported getting their information through the media, the traditional channel for raising awareness. The government in Cameroon has since switched the main focus of its investment in health education to mobilisers. The U-Report system is now used in 36 countries.

    Gavi is also working closely with countries to eliminate bottlenecks or gaps in vaccine supply chains. This includes replacing any faulty or underperforming equipment for storing and transporting vaccines.

    Haiti is among many Gavi-supported countries that have traditionally relied on fridges powered by kerosene to store vaccines at the right temperature. However, the combination of a devastating earthquake in 2010 and hurricane Matthew in 2016 severely damaged the country’s already weak power network and left vaccine safety hostage to a turbulent fuel market controlled by criminal gangs. Working with our Alliance partners, the government is now replacing these fridges with new solar-powered models.

    Similarly, scarce supplies of bottled gas have meant that cold chain managers in the Democratic Republic of the Congo (DRC) were frequently forced to travel great distances to purchase fuel for their fridges, often paying for it out of their own pockets. To address this and improve the security of the cold chain across the country, the government has provided more than 2,500 solar-powered fridges.

    By the end of 2016, Gavi had also funded the construction of 26 new primary healthcare centres (PHC) in previously underserved areas of DRC, with 14 more planned for 2017. In places such as Bokuda, in Sud-Ubangi Province, these have helped to not only plug gaps in vaccine coverage but also move towards the long-term goal of universal health coverage. The PHCs create a platform for a range of other health interventions, such as antenatal care, maternal and newborn nutrition, child health services, as well as reproductive health, family planning and counselling services.

    State-of-the-art equipment and primary healthcare centres alone would have little impact on coverage and equity without the right people to operate them. To this end, training is being improved across all Gavi-supported countries. The recent launch of the Regional Centre of Excellence for Vaccines, Immunisation and Health Supply Chain Management, based at the University of Rwanda in Kigali, represents one innovative example in the provision of training courses. Its Strategic Training Executive Programme (STEP) brings together universities from five African countries to mentor supply chain managers.

    All these initiatives contribute to achieving Gavi’s goals of eliminating gaps in both immunisation coverage and the supply chain. The two are mutually inclusive. It’s not enough to just find the missing millions. Once found, we need the right systems in place to ensure that every single missing child receives a full complement of vaccines.

  • Global coverage & equity

    Immunisation in Pakistan’s urban slums: a tale of two megacities

    Lahore and Karachi are two of Pakistan’s biggest and fastest-growing cities, together home to tens of millions of people. Yet in Lahore, significantly more children have been vaccinated against infectious diseases. The reasons why are salutary.

    Lahore

    Since 1998, Lahore’s population has almost doubled. Despite this, coverage with three doses of diphtheria-tetanus-pertussis- containing vaccine (DTP3) has soared from 24% in 2014 to 76% in 2016. Uniquely in Pakistan, tetanus has been eliminated in the surrounding province of Punjab. The last measles outbreak occurred in 2013.

    These successes are due to a combination of strong leadership, collaboration and a concerted effort to locate unvaccinated children. “We’ve done nothing revolutionary, just improved monitoring and surveillance,” says Dr Munir Ahmed, the Expanded Programme on Immunization (EPI)’s Project Director for Punjab Province and the man held responsible by many for the impressive improvement in vaccine coverage.

    “We had full support from the highest level. The chief minister gave his full ownership. We brought in IT solutions and built a surveillance dashboard which is available to all the districts and all the partners.”

    In another ground-breaking step, the EPI’s efforts to reach unregistered families living in Lahore’s urban slums are now supported by community-based vaccinators and communications staff hired by the Global Polio Eradication Initiative (GPEI). Importantly, the EPI and the GPEI have been brought together under one management team. “That is our strength. No other province has been able to do this,” says Dr Ahmed.

    Together, the EPI and GPEI are plotting maps of Lahore’s urban slums, helping to reveal where unvaccinated children may be living. They are also staffing community vaccination centres, and convincing hesitant parents of the benefits of routine immunisation.

    Karachi

    The population of Karachi, 1,000 km south-west of Lahore, has also grown rapidly, swelled by migrants attracted to the city’s bustling port and vibrant economy. The majority have ended up in the city’s slum areas, which have doubled in size since 2000. Plagued by violence and criminality, many have become no-go areas for health workers and international non-governmental organisations (NGOs).

    In Karachi, the precarious security situation and a lack of accurate population figures have conspired to limit the DTP3 coverage rate to less than 50%. Local vaccinators work in only 125 of Karachi’s 986 slums.

    “Anyone can survive in Karachi, this city feeds everyone,” said Dr Muhammad Amjad Ansari, UNICEF’s provincial immunisation officer. “But there is no check on how many people are coming to Karachi. Nobody knows the exact population or the situation these people are in. If you don’t know the population, how can you plan services like vaccination?”

    However, things are beginning to change and the Karachi EPI team is starting to feel more optimistic. Difficulties local authorities face in tracking unvaccinated children may be overcome by a slum mapping project jointly run by CHIP, a local civil society organisation, and UNICEF, with support from Gavi and the EPI. The approval of a new, long-term funding stream from Gavi has also enabled the Sindh provincial government to double their investment in routine immunisation. Nearly 200 extra staff have already been hired and another 1,000 vaccinators have been requested.

    Above all, the appointment of a new, committed EPI project director, Dr Agha Muhammad Ashfaq, is building momentum for improvements to the province’s routine immunisation programme. “We have done a lot over the past two years,” said Dr Ashfaq. “I believe the next survey will show that DTP3 coverage has risen to between 60% and 65%.” That’s up from 45% in 2015.

    “There is much improvement. There were big gaps for so many years, with training, with surveillance activities. Now, thanks to Gavi and the great UNICEF team out here, we cannot only stand. We can start to run.”

  • Global health security

    The rising risk of epidemics

    Events of 2016 underline the need for international action to combat new and emerging infectious disease risks.

    In February 2016, the world faced a new global health crisis. The Zika virus, already established in Brazil, was showing signs of spreading to new continents. More worryingly, the virus, which had previously been thought to cause only mild or no symptoms, was implicated in thousands of cases of congenital defects or nerve damage in babies.

    This unexpected public health emergency followed the devastating outbreak of the Ebola virus in west Africa, the largest in recorded history. Between 2014 and 2016, this latest epidemic killed more than 11,000 people and infected more than 28,000.

    With each disease demonstrating novel behaviours, either in the way the virus spread or in how it affected people, the global health community was caught off-guard.

    Traditionally, Zika was viewed as a cause of relatively benign asymptomatic or mild flu-like disease. The outbreak in Brazil changed this perception as evidence mounted of a link between more widespread infection and a sudden spike in the number of babies born with abnormally small heads, a condition known as microcephaly. Spread by Aedes aegypti mosquitoes, scientists feared the virus may be also sexually transmitted.

    Likewise, for decades Ebola has been a relatively low-impact disease, confined to small outbreaks in remote and relatively sparsely populated rural regions in Africa. Previous outbreaks were so aggressive that they usually immobilised and killed their victims before the virus had the opportunity to infect others. But in late 2014, Ebola reached densely- populated urban areas, where it was able to spread extremely rapidly.

    As both the Ebola and Zika outbreaks posed a threat to other nations, WHO declared each to be a public health emergency of international concern and called for international responses.

    Even by themselves, such outbreaks are a major concern. But when one considers that these recent events may become more common – and potentially have even greater catastrophic consequences – then those concerns become much more acute.

    There is a very real danger that climate change and the increasing mass movement of people and animals will spread diseases and their hosts to new parts of the world. The combination of population increases, land degradation, conflict and poverty, all of which fuel urban migration, means that viruses will have many more opportunities to proliferate in the world’s megacities. This could lead to a resurgence of large-scale urban epidemics of deadly infectious diseases.

    The potential for sudden shifts in viral behaviour or transmission makes future public health threats very difficult to predict. This coupled with the predicted increase in the number and scale of urban outbreaks will challenge our ability to respond, placing unprecedented stresses on our lines of defence and stocks of critical vaccine supplies.

    Millions at risk

    The summer of 2016 provided another serious wake-up call for the global health community, when the worst yellow fever epidemic in 30 years unfolded in Angola. For years, relatively small outbreaks of this mosquito-borne disease had been confined to rural areas of Africa and South America. However, in 2016 an outbreak spread to the Angolan capital, Luanda, where yellow fever vaccine coverage rates were low.

    Despite the distribution of more than 13 million doses of yellow fever vaccine, the virus also spread to Kinshasa in the neighbouring Democratic Republic of the Congo (DRC). It took a further 15 million doses to contain the epidemic.

    Approximately 90 million doses of yellow fever vaccine are produced globally each year. Emergency stockpiles stand at 6 million doses.

    To contain the epidemic in Angola and DRC, doses had to be diverted from preventive campaigns, risking outbreaks elsewhere and leaving emergency stocks severely depleted. To make existing supplies go further, in some regions WHO and UNICEF resorted to fractional dosing, administering just one fifth of the normal dose to each person.

    Yellow fever already kills up to 60,000 people a year. To date, it has not spread to Asia where more than 1.8 billion unvaccinated people live and any significant outbreak could spell disaster. No one knows why yellow fever has failed to establish in Asia, as the Aedes aegypti mosquito – which transmits yellow fever as well as Zika – is highly endemic in the region. In 2016, 11 cases did reach China, but they were contained.

    Prevention is everything

    The current levels of yellow fever vaccine stocks are not designed to cope with large-scale urban epidemics. But the world is changing. In 1950, two thirds of the world’s population lived in rural areas, and one third in urban settings. By 2050, this rural–urban split will likely have reversed. And as the number of megacities increases, each home to 10 million or more people, our emergency stockpiles of vaccines may no longer be adequate.

    These new realities have forced a reassessment both of the risks posed by infectious, transmissible diseases and the existing approach to preventing outbreaks. In December 2015, WHO brought together scientific experts to draw up a list of 11 diseases for which no drugs or vaccines currently exist. The list includes Ebola and other haemorrhagic fevers such as Marburg and Lassa fever, and Zika.

    In order to assist the accelerated development of vaccines which protect against the 11 diseases on WHO’s list, Gavi has been engaged in the establishment of the Coalition for Epidemic Preparedness and Innovation (CEPI). Founding partners include the Governments of India and Norway, the Bill & Melinda Gates Foundation, Wellcome Trust and the World Economic Forum.

    In addition, at the end of 2015, Gavi’s Executive Committee approved an Advanced Purchase Commitment, providing US$ 5 million towards the costs of the development of a candidate Ebola vaccine. In return, the Committee asked that 300,000 doses be made available and for the vaccine to be submitted for licensure by the end of 2017. Once approved, a stockpile will be created. However, increasing emergency stockpiles, including for new vaccines once they have been developed, is only part of the solution. The best way to prevent major disease outbreaks is to stop them happening in the first place by investing in public health infrastructure.

    Strong health systems help prevent future outbreaks via pre-emptive vaccination campaigns and supporting high levels of childhood immunisation.

    They also improve surveillance and the ability of fragile countries to identify and respond to outbreaks quickly.

    The experiences of 2016 have provided some salutary lessons. In Brazil, efficient surveillance by public health workers rapidly established the link between rising numbers of babies born with microcephaly and the spread of the Zika virus. In contrast, in west Africa, where health systems are less well equipped and disease surveillance is more limited, at least three months passed between the first person being infected with Ebola and a laboratory confirming the spread of the virus.

    The case is clear. Strengthening routine immunisation systems in the poorest countries not only helps save vulnerable lives, it also makes the world safer by mitigating the growing threats to global health security.

  • Global health security

    A new kind of fragility

    From a global health perspective, Syria’s humanitarian crisis has revealed a new kind of fragility that has required a new kind of response.

    Since the start of the current conflict in 2011, Syria’s immunisation coverage has plummeted to just 42%; it is now the third lowest among 84% vaccine coverage, pre-conflict coverage falls, the risk of infectious disease outbreaks rises. Cases of polio, measles and meningitis are also likely to become more common.

    In December 2016, the Gavi Board responded to the humanitarian crisis in Syria by pledging up to US$ 25 million a year for two years to support emergency vaccination campaigns and to provide cold chain equipment. The aim is to help UNICEF and partners immunise 3 million Syrian children under the age of five.

    The challenge will be reaching those 3 million children when more than a third of Syria’s remaining population has been uprooted from their homes. Seven years of conflict have displaced more than 11.1 milliona people. Many have reached humanitarian camps, but an additional 4.9 million are trapped in besieged cities and hard-to-reach areas.

    People caught up in conflict are often invisible to humanitarian agencies yet highly vulnerable to infectious disease. Large numbers of unvaccinated people living in close proximity, with limited access to water and sanitation, represent a fertile breeding ground for outbreaks.

    This situation is not unique to Syria. In 2008, roughly 60% of all internally displaced persons (IDPs) were located in rural areas with the majority residing in humanitarian camps. Now, nearly 10 years on, roughly the same percentage of IDPs seek refuge in urban areas while just 1% shelter in camps. Far from fleeing cities, most of the world’s 65 million displaced appear to be hiding in them.

    For global health organisations, this new type of fragility has serious implications. New solutions are needed to reach displaced persons, be they fleeing conflict, persecution, climate change or poverty. To begin to address such issues, Gavi has introduced a new fragile state policy, which provides the Alliance with the flexibility to tailor support to a country’s individual needs.

    a – Source: United Nations Office for the Coordination of Humanitarian Affairs report, December 2016

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