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  • Sri Lanka:
    Six steps to sustainability

    Sri Lanka, which reports a near 100% coverage rate, is one of four countries scheduled to graduate from Gavi support in 2016. Dr Ananda Amarasinghe of the Health Ministry’s Epidemiology Unit reveals the secrets behind the country’s immunisation success story.

    1. MAKE FAMILIES AWARE OF VACCINES

    Remarkably mothers who lost everything either as a result of civil conflict in the north-east or the 2005 tsunami which devastated the south, still possessed their children’s immunisation cards. “It shows their recognition for immunisation as a guarantee of a better future for their children,” says Dr Ananda.

    It also demonstrates the importance of Sri Lanka’s high literacy rates with mothers and fathers highly aware of the benefits of preventive care. For example, hospitals are preferred to home deliveries. When the pentavalent roll-out was suspended in 2008, following reports of adverse reaction to the vaccine, the Health Ministry was rapidly able to reassure families about the five- in-one vaccine’s safety. “Mothers temporarily questioned pentavalent but they never lost their faith in immunisation,” says Dr Ananda.

    2. CONNECT WITH GRASSROOTS COMMUNITIES

    Sri Lanka’s near-100% immunisation coverage rate owes much to a nationwide network of 4,000 community-based healthcare workers. There is approximately one health worker for every 5,000 Sri Lankans. Regular door-to-door visits, usually by bike or scooter, mean each is always up to date on their patients’ state of health.

    The health workers hold regular outreach clinics raising awareness of antenatal care, immunisation and maternal and child health – and also registering every newborn child. If a mother or father fails to bring their child to a vaccination session, the health worker visits their home and, in some cases, personally accompanies the child to her clinic for immunisation.

    3. BUILD TOP TO BOTTOM PUBLIC HEALTH STRUCTURE

    Sri Lanka’s public health system, which dates back to the 1920s and the time of British rule, provides a mix of curative and preventive services at national, district and divisional levels. “Our colonial masters established a good foundation,” says Dr Ananda. It ensures a steady flow of information from grassroots communities to the Health Ministry for monitoring and evaluation. Regular updates on local immunisation coverage rates are delivered to Colombo and are often available online thanks to a new online registration system.

    The system works both ways. When launching pentavalent vaccine in 2008, the Ministry enforced a new open vial policy by meeting with 26 district EPI managers, who, in turn, informed the 330 divisional offices. “We told them if some doses remain, don’t discard them,” says Dr Ananda. Instead of 10% wastage, the Health Ministry registered less than 1% – enough vials to provide for one month of vaccinations.

    4. SECURE POLITICAL SUPPORT

    Even during the civil conflict, temporary ceasefires allowed hospitals and clinics to deliver immunisation and other basic health services.

    Successive Sri Lankan administrations have prioritised free health and education.

    In 2014, the Government introduced a national immunisation policy guaranteeing every citizen the right to vaccination. There is a separate line in the national budget for immunisation ensuring continuity in the delivery of vaccines and virtually no stock-outs. “It is the responsibility of our people to get vaccinated so the Government guarantees the availability of vaccines,” says Dr Ananda.

    5. INVEST IN LONG-TERM TRAINING

    To ensure the long-term sustainability of its immunisation programme, the Health Ministry invests in training future generations of public health inspectors and health workers at six regional training centres and one national centre. “No matter how many clinics you build, you can’t provide services without trained resources,” says Dr Ananda, “We want our successors to do even better than us.” Since the end of the civil conflict in 2009, the training centre at Vavuniya in the north of Sri Lanka has trained over 600 health workers to help rebuild the health system in the former conflict zone.

    Under the colonial administrative system, all government officers learnt their trade in rural areas before moving to the major cities. Today, Sri Lanka’s public health staff must also gain extensive experience working at divisional then district levels before moving to the Ministry in Colombo. “Before we come to the centre, we need to know the reality on the periphery,” says Dr Ananda.

    6. CONTINUE TO LEVERAGE GAVI’S EXPERTISE

    When Dr Ananda was asked to draft Sri Lanka’s first application for Gavi support in 2000, he had to look in the files to find out about the Vaccine Alliance. Now, he is very clear about how Gavi can continue to help countries like Sri Lanka after they have graduated.

    The Health Ministry has already asked the Vaccine Alliance to help negotiate a fair price for the HPV vaccine, which Sri Lanka plans to include in its routine immunisation schedule in the near future. “That is where Gavi can help,” says Dr Ananda, “We wish to rely on ourselves. We know that the UNICEF procurement system is one option, but we have the money and can procure the vaccine ourselves. But with our small population, we are not in a position to bargain with the manufacturers. That is what we ask of Gavi: can you help as a negotiator?”

  • MENAFRIVAC:
    DEFROSTING THE COLD CHAIN

    By removing the need for ice packs during the final stage of some vaccines’ journeys from manufacturer to clinic, the controlled temperature chain (CTC) is transforming the immunisation supply chain.

    For health workers and vaccinators in Boulohou, a village in the central region of Togo, a typical day begins at 5.30 am with the preparation of what is arguably their second most treasured cargo – ice. It protects the precious vials of vaccines from the punishing African sun, ensuring that they remain effective and safe when administered.

    Useful as it is, ice comes with its own challenges. It requires power and resources to produce and places a limit on the amount of time a vaccinator has to get the vaccines out to the community and – in the case of any unused vials – back again. Ice also requires conditioning, a time-consuming process whereby the temperature of the ice is raised to 0°C through partial melting, to prevent sub-zero temperatures from damaging the vaccines through freezing. For just as heat can harm vaccines, so too can extreme cold.

    In 2014, Gavi funding helped health workers in Togo take part in a ground-breaking trial of a radical new approach to vaccine delivery, which removes the need for ice during the final stage of a vaccine’s journey.

    Using a combination of vaccine vial monitor labels (VVMs) and peak temperature threshold indicators (PTTIs) to create a controlled temperature chain (CTC), Togolese health workers conducting a 10-day meningitis A campaign were able to safely maintain MenAfriVac vaccines outside the cold chain for up to four days, provided their temperature did not exceed 40°C.

    By simplifying their job and reducing their load by several kilos, the new CTC approach had an extremely positive impact on the day-to-day lives of vaccinators and healthcare workers. According to WHO epidemiologist Dadja Essoya Landoh, who formerly worked for the Togo Health Ministry and was involved in last year’s campaign, CTC can halve the number of vaccinators involved because removing the need for ice frees up more space in the container. One vaccinator can then carry more vials.

    It can be difficult for vaccinators to reach some of the older people in the target population because they are often at work from early in the morning until late in the evening. However, CTC vaccinators are not constrained by the condition of their ice and do not have to head back to base to return unused doses to refrigerators.

    Instead, according to Landoh, some vaccinators stay overnight in local villages, so they can catch farmers as they come in from the fields or before they head out in the morning. With more than a million people aged between 0–29 years targeted by Togo’s meningitis A campaign, this can add up to a lot of people that would otherwise have been missed.

    In addition to anecdotal evidence that the vaccine shots are less painful, because they are delivered at ambient temperature, there is a growing belief that CTC will also reduce costs. With one pneumococcal vaccine pre-approved for a CTC approach in 2015, and several others in the pipeline, CTC could be about to revolutionise the supply chain.

  • Yellow fever vaccine:
    Increased demand requires innovative solutions

    The hard work done by Gavi and its partners to increase immunisation against yellow fever over the past 15 years has been so successful that more vaccine was urgently needed to meet global demand.

    Just over a decade ago, 20 million doses of the yellow fever vaccine were enough to supply global demand for this vaccine. But with yellow fever now included in routine immunisation programmes in a growing number of countries and a global stockpile that needs regular replenishment, demand has surged to around 80 million doses a year for Gavi-supported countries alone.

    With only four prequalified yellow fever vaccines available worldwide, one of Gavi’s biggest challenges in 2014 was to find a way to encourage additional capacity. Building on work by WHO and other Alliance partners, the Institut Pasteur de Dakar in Senegal and Sanofi Pasteur in France decided to invest in facilities to grow production capacity, thereby ensuring adequate supplies of this much needed vaccine for Africa.

    The Institut Pasteur de Dakar (IPD) has been manufacturing its yellow fever vaccine since the 1930s, which makes it the oldest, most experienced producer in the world. The vaccine itself – like all yellow fever vaccines – also dates from the early years of the last century. The live, attenuated vaccine is produced using chicken eggs and embryos, and the required levels of sterility are difficult to achieve. With growing demand and a rapidly increasing population in endemic areas, outside investment was urgently needed to ensure the continuing viability of the IPD plant.

    “As the African population continues to grow, increased production of the yellow fever vaccine will certainly be needed,” said IPD Director, André Spiegel. He added that this increased demand is best met by a vaccine manufacturer and supplier based in Africa, focusing on a serious health challenge for the continent. So when the team from the Vaccine Alliance came to visit, he was more than open to a partnership that enables his institute to invest in producing yellow fever vaccine and so guarantee a secure future supply.

    “Gavi’s work in this area has allowed us to maintain and sustain production of the vaccine for Africa in Africa,” Dr Spiegel said.

    While IPD focuses almost entirely on meeting demand in Africa, Sanofi Pasteur has its eyes on two separate markets: people living in endemic areas, and travellers visiting those areas. To meet growing demand in both markets, Sanofi Pasteur has invested in a new plant that will produce enough vaccine to contribute to the global emergency stockpile as well as meeting annual demand in developing countries. This is a tale of two solutions.

    By encouraging more countries to introduce yellow fever vaccine into their routine immunisation schedule, the Vaccine Alliance and its partners have substantially increased stable demand. Now, after investing time and effort in strengthening key supply sources, Gavi hopes that the capacity will soon be in place to meet the full needs of countries as well as the global stockpile used to respond to outbreaks of the disease.

  • DELIVERING TOGETHER:
    UNITED PARCEL SERVICE AND
    THE VACCINE ALLIANCE

    In 2014, United Parcel Service (UPS) announced a partnership with Gavi. Ed Martinez, President of the UPS Foundation, explains how UPS will apply more than 100 years experience in running supply chains and over 50 years in business philanthropy to modernising the vaccine supply chain.

    What are the origins of the UPS corporate social responsibility programme?

    Our founder, Jim Casey, saw the United States go through the toughest of times – depression, World Wars One and Two, the civil rights and womens’ rights movements. He felt that for a business to survive, the community has to be healthy and prosperous. So he started the UPS Foundation in 1961.

    Half a century later, we support over 4,000 organisations globally ranging from community- sized nongovernmental organisations to large entities the size of the Vaccine Alliance. Our focus has changed over the years but our philosophy remains the same, whether it’s applied in Atlanta or Hanoi, to help civil society with our expertise, our resources and the hard work of our employees around the world. If a UPS staffer wants us to make a financial contribution to a local NGO, they have to devote a minimum of 50 hours of their own time and expertise to their chosen cause.

    Most of your private sector partners are humanitarian organisations focused on emergency response like UNHCR, the World Food Programme (WFP) or Care. Why did UPS choose Gavi?

    There are three ways UPS can help humanitarian programmes: preparedness, urgent response and post-crisis recovery. Today, we help 11 global organisations that specialise with one or more of these workstreams: United Nations agencies like UNHCR, UNICEF and OCHA and NGOs such as Care and the Salvation Army. But we are always looking for ways to garner greater impact and that’s where the conversation with Gavi started.

    Some of your partners are either our partners or our customers so there’s enormous potential to build synergies. For example, we work with UNICEF and one of your partners, Merck (a pharmaceutical company), is a UPS customer. That’s a perfect opportunity to share expertise to build a more effective cold chain for vaccines.

    The immunisation supply chain is under strain because of the number of new vaccines. How can UPS help the Vaccine Alliance’s supply chain strategy?

    Gavi works with very professional organisations like UNICEF and health ministries, but I think UPS can bring a different skill set to the table. Transportation and supply chains have been our core competency for 100 years and I believe there are elements of the immunisation supply chain that we can enhance. Inventory management is vital to avoid wastage. Tracking technology can ensure that beneficiaries receive life-saving commodities more quickly and efficiently.

    The UPS Relief Link is an example of modern-day tracking technology. It’s helping UNHCR accelerate the delivery of commodities to refugee camps and also monitor the level of nutrition in the camps. It’s perfectly replicable in the distribution of vaccines.

    Is UPS support limited to logistics?

    Delivering packages is just one piece of the partnership. We believe that besides saving time, a lot more can be done in the management of the supply chain to save resources and increase the number of products.

    Like any business process, supply chain initiatives need strong leadership. We have offered Gavi training not only in supply chain management but also in leadership. This will deliver well trained supply chain managers in Gavi countries.

    How has UPS already drawn on its global resources to help humanitarian agencies?

    Last year, we used UPS aircraft based in Cologne, Germany, to transport UNHCR and UNICEF equipment to countries worst hit by the Ebola epidemic. And when WFP needed a logistics capacity assessment in Nigeria, we put out a call to our local office. They delivered an assessment within a couple of weeks.

    What are the first steps and how will you measure the success of your partnership with Gavi?

    First, we are working together to build a strong foundation based on supply chain best practices. Then, we’ll dive into the specific cold chain needs of individual countries in Africa and Asia, apply best practice and find solutions.

    We’re working with the Alliance to develop metrics so we can measure progress five years down the road. But, ultimately, the goal is to ensure healthier communities everywhere. We’ll know that we’ve been successful when those communities no longer need our help.

  • SMARTPHONES
    IN INDIA:
    DIAL V FOR VACCINE

    Even in the remotest areas of Uttar Pradesh, health workers use smartphones to track vaccine stock levels in real time. Now Gavi health system strengthening support will ensure this innovative approach dials-in three large Indian states.

    At the end of a busy vaccination session, Mitra Kumari needs to take stock, literally. As a cold-chain handler for the Bareilly Primary Health Center in Uttar Pradesh, India’s most populated state, she needs to know that she has enough vaccine doses in stock for the next day’s immunisation session.

    Instead of returning to the cold store, Mitra reaches for her phone. At the push of a few buttons she can quickly see how many doses she has in stock and when these stock levels were logged.

    Piloted in two districts, the new Electronic Vaccine Intelligence Network (eVIN) is transforming the way vaccine stock is managed and making the distribution of vaccines much more efficient. “Since the introduction of this technology, it has become easier for me to maintain the record systems,” says Mitra. The interactive system is designed to work across different platforms, from the latest smartphones to the most basic text-based handsets. “It is very easy to use,” says Mitra.

    In addition to checking stock, eVIN also allows cold-chain handlers, like Kumari and her colleague Surajmukri Gangawar, to update the system in real time by logging the number of used, open or discarded vials. It can even track temperature levels of cold storage facilities.

    By standardising and streamlining vaccine logistics management, eVIN has already had a profound impact on the supply chain in the two districts where the pilots have taken place. In the first six months of implementation, vaccine stock-outs have been virtually eliminated.

    “Now, with Gavi’s health system strengthening support, the plan is to scale this up across three large Indian states – Uttar Pradesh, Rajasthan and Madhya Pradesh – which have a combined population of 345 million,” says Bhrigu Kapuria, Team Leader for Vaccine Logistics & Cold Chain Management, for the Government of India’s Immunization Technical Support Unit. “This is going to help improve immunisation coverage,” he says.

  • Living proof:
    Impact of pneumococcal vaccine in Kenya

    Surveillance studies supported by Gavi at the Kenya Medical Research Institute (KEMRI) in Kilifi are helping to establish to what extent pneumococcal vaccines have contributed to the recent drop in the number of reported pneumonia cases.

    Lying on a hospital bed, the tiny figure of an infant struggles for breath, his hands bandaged to stop him from pulling the oxygen tube from his nose. “We see a lot of pneumonia,” says Mwanavua Boga. “Some, when they come in, are very severe. They need a lot of intense care. They are often very sick and the mothers are very worried.”

    “This infant is one of the lucky ones. He has made it through the worst of the infection and is now on the mend,” says Mwanavua, who is Head Nurse of the Kenya Medical Research Institute (KEMRI) High Dependency Unit at Kilifi County Hospital. During the 13 years she has worked there, pneumonia has consistently been the biggest killer of under-fives. “It’s the number one cause of admissions on the ward,” she says. However, since 2011, the number of cases of pneumonia appear to have fallen after the Government of Kenya, with Gavi support, introduced pneumococcal vaccines.

    As pneumonia has a number of different causes, which can vary in different parts of the world, it was not clear how much of the drop in cases was down to the pneumococcal vaccine. To help determine the impact of the vaccine, researchers at KEMRI carried out a comprehensive series of studies to establish whether the vaccine was as effective as it had appeared to be in the controlled setting of clinical trials. “These studies are important,” says Mwanavua. “They give us a perspective of what our problems are and, in terms of planning for the future, what vaccines we need for our children,” she says.

    However, identifying the precise cause of pneumonia is far from straightforward and often requires indirect methods. For example, in one approach, field researchers were sent out into the community to take swabs from healthy members of the population, chosen at random. Pneumococcal bacteria live in the back of the nose and throat of both healthy and sick people; by measuring the bacteria’s prevalence in the community, it is possible to gauge their ability to spread. Researchers found that within six months of the vaccine’s introduction, there was a two- thirds reduction in carriage of strains targeted by the vaccine, in both vaccinated and unvaccinated individuals.

    This valuable research was only made possible because researchers at KEMRI had the foresight to begin pneumococcal disease surveillance, with Gavi support, four years before the pneumococcal vaccine was introduced in the region. This provided researchers with a clear reference point to help measure the vaccine’s impact.

    In addition to this, tracking of hospital admissions showed that the number of cases of pneumonia has dropped by a quarter, with a reduction in radiologically proven pneumonia largely caused by pneumococcus bacteria. In addition, major declines in cases of invasive pneumococcal disease (IPD) – a very severe but less common form of pneumococcal disease – have been seen. “Kilifi often used to see more than 40 cases of IPD a year,” reports Dr Anthony Scott of the KEMRI-Wellcome Trust Research Programme. “When we introduced the vaccine the numbers fell quite rapidly,” he says.

    In the whole of 2013 and 2014 only one case of vaccine-specific IPD was reported, representing a 95% drop over pre-vaccination levels. “That’s a very dramatic change in the epidemiology of the disease,” says a delighted Scott. “Essentially we’re at the point where we think that disease is controlled. It’s almost gone.”

  • Final push
    against polio:
    Punjab shows the way

    The successful introduction of the inactivated polio vaccine in Punjab province will depend on a new plan to strengthen the routine immunisation system

    It’s not often you pick up the phone and hear the voice of a senior minister at the other end, asking how you think local immunisation services could be improved. Yet this is soon to become reality in Punjab province, where Chief Minister Shehbaz Sharif is so committed to public health services that he has recorded a personal telephone message inviting citizens to share their experience of vaccination.

    This is just one example of how the Punjab province, home to more than half of Pakistan’s population, is committed to improving its routine immunisation system and, ultimately, eliminating polio.

    “Pakistan accounts for about 80% of the world’s polio cases and we have measles outbreaks – things the rest of the world has largely overcome. And I attribute that largely to a poorly executed and managed vaccination system,” says Dr Umar Saif, head of the Punjab Information Technology Board.

    Pakistan is one of just three remaining polio-endemic countries, and is expected to introduce inactivated polio vaccine (IPV) with support from Gavi later this year. Reaching every Punjabi with the vaccine will depend on a strong routine immunisation system, so the province has introduced a new plan to help strengthen its capacity.

    Supported by partners such as the UK Department for International Development (DFID) and UNICEF, the plan includes re-allocating vaccinators’ time from campaigns to routine immunisation, as well as providing training and even fuel allowances to help vaccinators move between communities.

    The plan is expected to provide new momentum to boost the delivery of vaccines against other diseases as well.

    “Routine immunisation is key to polio eradication,” explains Aizaz Akhtar, head of the Special Monitoring Unit of Punjab’s Chief Minister’s Office. “Any study confirms that when routine immunisation coverage gets up to 95% your polio cases will go down. And that’s the story we need to tell.”

    To help public health managers track progress and set targets, Dr Saif and his team have developed a smartphone app, funded by the World Bank, which allows vaccinators to quickly register every jab on a central data hub. Results have been impressive. “We have witnessed a sea change in the way vaccination is done. Vaccinators used to meet 21% of their targets. With the new app, this has increased to 91% in just four months,” he said.

    Dr Captain Asif, the health manager in Jhelum district, is optimistic. “We are really pleased with the new system. Our experience has been a good lesson for the rest of Pakistan!”

    Punjab’s plan marks a milestone in the country’s long journey to eradicate polio and strengthen routine immunisation systems. Dr Saif, Mr Akhtar and Dr Asif are all positive about its potential to work in other provinces, because, says Dr Asif, it is “making vaccines accessible at the doorstep of each child”.

  • GLOBAL COVERAGE RATES:
    THE THREE BIG COUNTRIES

    As Gavi shifts its focus and attention towards increasing coverage and equity, it is important to remember that any progress towards global targets very much depends on what happens in just three large, highly-populated countries

     

    INDIA

    In 2014 India accelerated its national roll-out of pentavalent vaccine with a further 12 states introducing the vaccine with Gavi support. These states alone account for 50% of India’s 25.5 million strong birth cohort, with another 15 states, representing 35% of the national birth cohort, due to complete the vaccine’s introduction by early 2016. The Government will be taking up the cost of pentavalent vaccine from 2016. Since 2010, India has increased DTP3 coverage from 79% to 83%. The switch to pentavalent vaccine will also provide protection against hepatitis B and Hib infection.

    INDONESIA

    Indonesia successfully completed the nationwide introduction of pentavalent vaccine across its 6,000 islands in less than two years – half the time it took to roll out the tetravalent vaccine (DTP and hepatitis B). However, DTP3 coverage rates dropped to 78% in 2014. The national immunisation programme also reported a four-month stock-out in the first half of the year. This underlines how supply issues and geographical challenges can heavily impact a large country’s ability to achieve and maintain high coverage.

    NIGERIA

    After falling to 42% in 2012, Nigeria’s coverage with a third dose of DTP-containing vaccine rose to 66% in 2014 – the highest level ever.

    While Nigeria is one of Africa’s wealthiest countries, it has the highest number of vaccine-preventable deaths in the continent. However, in 2014 the Government, with support from Gavi, boosted its routine immunisation programmes by improving an historically poor vaccine supply chain infrastructure. This included the procurement and installation of over 1,500 Solar Direct Drive fridges and freezers.

  • Update from Afar:
    Islamic leaders champion immunisation

    Imams in one of Ethiopia’s remotest regions are helping break cultural and geographical barriers to immunisation.

    A doctor’s waiting room crammed full of women and children waiting for routine immunisation is a common enough sight in many rural African communities. However, in Ethiopia’s vast Afar region, where families are constantly on the move searching for water and fresh pasture for their cattle, health workers have to go out and look for their patients.

    Geography is only one of several barriers to increasing immunisation coverage rates in a region where less than a quarter of all children receive the basic package of vaccines. Even when health workers find Afar’s shifting communities, they must overcome deeply entrenched fears and suspicions of vaccines. One nurse has described being threatened by an angry father after approaching his child for a routine immunisation check.

    Yet the children of Afar cannot afford to miss out on the protective powers of vaccines. When a child falls sick here, they must travel vast distances to receive even the most basic level of medical treatment.

    Recognising the need for a fundamental shift in the community’s beliefs, Afar’s Regional Health Bureau turned to influential religious leaders such as Sheik Mussa Mohammed, a highly respected Islamic scholar and deputy head of the regional Islamic Affairs office.

    With support from PATH and Gavi, the Health Bureau and the Islamic Affairs office invited more than 40 imams to attend an advocacy workshop on immunisation and plan how to spread the word about the importance of vaccinating children. Sheik Mussa cited a passage from Reflection of Islam in the Quran on Child Care and Protection which tells Muslims that it is their religious duty to protect children from any illness, including vaccine-preventable diseases.

    Subsequent workshops involving more than 100 imams from across Afar have resulted in widespread dissemination of immunisation messages in mosques during Friday prayers and at religious events. During Nika – the marriage vows ceremony – imams often call upon couples to vaccinate their future children.

    One year after first reaching out to the Islamic community, Ibrahim Gudelle, head of the Maternal and Child Health Unit at Afar’s Regional Health Bureau has already noticed an increase in immunisation coverage rates.

    Following the success of its initial pilot project in Afar, the Regional Health Bureau is expanding the partnership with PATH and Gavi and reviving social mobilisation committees across the region. First established several years ago, the committees are composed of respected members of the community including administrators, clan and religious leaders, womens’ groups and health and education authorities.

    “I am happy to inform you that we have seen a lot of successes, particularly in increasing our region’s coverage with the basic package of childhood vaccines. It’s a result of the involvement of Islamic leaders,” says Mr Gudelle.

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