FT Health: The threats to vaccine progress

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The guest curator of this week’s FT Health is Seth Berkley , chief executive of Gavi, a public–private alliance that improves access to immunisation in poor countries:

I was at the World Health Organization this week discussing two worrying trends: the first increase in years in polio cases in Afghanistan and Pakistan, the last two remaining countries with wild polio; and a rise in vaccine-derived polio outbreaks. I saw the latter first-hand in Papua New Guinea this year, where an outbreak in one province quickly spread across the country because of low routine vaccine coverage.

As the long tail of the eradication effort keeps getting longer and longer, it made me reflect on the raft of concerning news we have had over the past few weeks: measles and malaria cases rising, which puts decades of progress at risk; the Ebola outbreak in Democratic Republic of Congo continuing to grow; and the looming spectre of antimicrobial resistance hanging over us all.

But by focusing on the challenges ahead, we can forget how far we have come: there were 350,000 cases of polio a year in 1988 and 545,000 cases of measles in 2000. We should be inspired by continued progress: in recent weeks both Senegal and Ethiopia introduced human papillomavirus vaccine into their routine immunisation programmes, which will protect hundreds of thousands of girls against cervical cancer.

Next week Gavi will host its Mid-Term Review, where we will be balancing the good news with the challenges ahead. We celebrate the 10m lives saved since our inception in 2000 and 18 years of real progress in the global effort to ensure every child has access to vaccines.

But with that progress slowing in recent years, there are clouds on the horizon. Our challenge now is to build resilient health systems to reach the very hardest to reach: children in remote communities or off-the-grid in sprawling urban slums; and child refugees or those living in conflict zones where health workers have to risk their lives just to reach them. For if they lack access to vaccines, they are unlikely to have access to any health interventions. 

In the past, most deaths in wartime were caused not by trauma but by infectious disease. In modern times, vaccines changed that. Now, however, we are struggling in our ability to take vaccines to people affected by conflict. That is causing unnecessary deaths in DRC, for instance, where insecurity and mistrust have blocked access to effective Ebola vaccines.

The same is happening in Yemen, described in my interview below with Fouzia Shafique, Unicef chief of health and nutrition in the country, who worked with Gavi and the WHO to bring together health authorities from the north and south for the first time since the conflict started.

That has helped ensure children in both regions are protected with vaccines and has built much needed trust. I hope the story inspires you as much as it did me and helps prove that even in the gloomiest circumstances — arguably the world’s worst humanitarian crisis — there is still good news to be found.

Books I'm reading

Sapiens, A Brief History of Humankind by Yuval Noah Harari. Leonardo da Vinci by Walter Isaacson

Just finished: Factfulness by Hans Rosling; I Contain Multitudes: The Microbes Within Us and a Grander View of Life by Ed Yong

Three Questions

Dr Fouzia Shafique, Unicef Yemen Chief of Health and Nutrition

How were the two warring parties brought together? What was your role there and their motivation for coming? 

Unicef has always advocated for keeping health neutral, apolitical and a right of the entire Yemeni population. The health authorities in Aden and Sana’a . . . are willing to co-operate. The end of one phase of Gavi support to Yemen’s health system and the need to prepare and submit a new plan for the next phase this year required inputs from both sides.

The support is strategic and important for Yemen, so the motivation for both authorities was not only to maintain a good close and strong partnership with Gavi but also to show willingness to work together in the interest of the Yemeni population. After months of discussions and hard work from both Unicef and Gavi, we were able to bring both authorities together in Beirut.

What impact will the Beirut meeting have on the health of the Yemeni people?

The primary result of the meeting is well beyond the scope of the discussions there. It is the realisation and recognition that the two authorities in charge of public health can work together and agree on common principles and strategies. This will serve many other programmes if it can be replicated. If the two sides continue to work together it would mean the timely implementation of health activities that could save many lives and prevent the collapse of the health system. This would be a very remarkable outcome. 

What challenges are you facing with immunisation in Sana’a? How are vaccinators reaching children in what is effectively a war zone?

A combination of conflict, operational difficulties related to the importation of vaccines and lack of agreement on vaccination schedules has had a detrimental effect on coverage in some parts of the country, including refusals or concerns around vaccination. But as a result of concerted advocacy by Unicef, Gavi and other partners, several of the bottlenecks have been overcome and progress is being made to reach more children, including in hitherto hard to reach areas. A cholera vaccination campaign has been conducted in both north and south; polio and other campaigns are being conducted as planned. Another major breakthrough has been the recent polio and measles/rubella vaccination campaigns in Saada, a governorate where vaccination campaigns are not usually allowed and refusals from communities and leaders are high.

Chartwatch

Articles I'm reading

15 years later: How well are we doing addressing Aids, Bill Frist (Forbes)

Throwing open the schoolhouse doors, once and for all, Gordon Brown (NYT)

It isn’t crazy to conduct an Ebola clinical trial in a war zone — it’s necessary, Jeremy Farrar (STAT)

A generation of widows, raising children who will be forged by loss (NYT)

Study shows mitochondrial DNA can be passed through fathers — what does this mean for genetics? (The Conversation)

DRC’s solar revolution (Gavi)

A novel way to stop the spread of antibiotic-resistant bacteria (Economist)

Powdered polio vaccine brings hope to Nigeria and Pakistan (Guardian)

The silent epidemic killing more people than HIV, malaria or TB (hep B) (Nature)

Academic papers

The state of vaccine confidence (Lancet). Professor Heidi Larson puts forward a five point plan for boosting vaccine confidence across the globe. She highlights that the reasons for hesitancy are context-dependent, so must be addressed at the local level.

Flu virus is a master shape-shifter (Nature). Interesting study showing that the structure of a flu virus can vary dramatically even within a single infected cell thanks to “low-fidelity” assembly, which could contribute to the challenge of developing flu vaccines.

Global molecular epidemiology of HIV-1: the chameleon challenge (Lancet Inf Dis). The global genetic diversity of HIV is one of the biggest challenges faced in vaccine development against the virus. Continued global mapping of the distribution of strains could be a valuable resource in focusing research efforts.

The 2018 report of the Lancet Countdown on health and climate change: shaping the health of nations for centuries to come (Lancet). This report on health and climate change calls it the “biggest global health threat of the 21st century”.

Scientific communication in a post-truth society (PNAS). We have seen the direct impact of vaccine misinformation on health with the rise in measles cases across Europe and the US. An interesting paper looking at how best we can communicate science to the public in a post-truth world.

21st-century typhoid fever — progression of knowledge but regression of control? (Lancet). Mortality rates could be as high as 20 per cent, until the widespread use of antibiotics helped us reduce deaths to 1 per cent. But this progress is under threat thanks to the spread of drug-resistant strains.

The potential effect of improved provision of rabies post-exposure prophylaxis in Gavi-eligible countries: a modelling study (Lancet Inf Dis). New findings suggest that improving access to post-exposure prophylaxis against rabies would be highly cost-effective and could prevent nearly half a million deaths between 2020 and 2035.

Alma-Ata at 40 years: reflections from the Lancet Commission on Investing in Health (Lancet). The Lancet Commission on Investing in Health puts together a new report on how to deal with health in lower and middle income countries and the critical role that primary care plays in this.

Your thoughts on 2018 — and beyond

What were your highlights and low points for global health this year? And what do you think will be the big themes for 2019? Email health@ft.com or tweet us @fthealth and we will feature the best responses in our year-end issue.

Podcast of the Week

Podcast: are food allergies becoming more common? Medical experts and a sufferer discuss why concern is rising about reactions to foods (FT)

Global health film festival

Watch a trailer for Ama, the story of the sterilisation of American Indian women since the 1970s. Part of the Global Health Film Festival in London this weekend.

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