Last week’s announcement of the Minamata Convention on Mercury represents a huge step forward in international efforts to reduce the human health impacts of mercury. For GAVI what is most important about the global and legally-binding treaty is what was left out. The treaty made an exception for thiomersal, a mercury-based preservative that has been used in some vaccine manufacturing since the 1930s to prevent bacterial or fungal contamination of multi-dose vials of vaccine.
The treaty exception represents a triumph of science over the politics of fear. The anti-vaccination lobby pressed hard to have thiomersal – known as thimerosal in the US – included in the treaty despite the scientific evidence that thiomersal poses no human health risk. Indeed, banning it would have disrupted vaccination programs in many developing countries, putting millions of children at risk from vaccine-preventable illness.
The anti-vaccine lobby has been successful in raising fears and doubts about the adverse effects of vaccination and the role of thiomersal in increases in developmental disorders and autism. With parents, scientists and even initially the American Academy of Pediatrics (AAP) weighing in, the United States implemented a precautionary reduction more than a decade ago. There is now a mountain of scientific evidence refuting any link between thiomersal and autism, and AAP reversed their 1999 position that called for elimination of mercury in vaccines. GAVI and AAP share a belief that scientific evidence should guide public policy, and the evidence on thiomersal is clear. It is a safe preservative used in multi-dose vaccines, and at this time there is no replacement for it. Good science and a good global policy.
At GAVI our goal is to reach the world’s poorest children with life-saving vaccines, and while we are pressing for innovations in vaccine delivery systems, the realities of the current cold chain and storage capacities in developing nations make multi-dose vaccines containing thiomersal a necessity. Without it the number of children receiving vaccines in in 120 countries, mostly in the developing world, would plummet. The World Health Organization estimates that thiomersal-containing vaccines avert at least 1.4 million child deaths every year by protecting children from fatal diseases, such as diphtheria, tetanus, and hepatitis B (1). By using multi-dose vaccines, we can reach more children, and we can save more lives.
It is encouraging to see that the treaty negotiators used good science to inform this important global policy. We need to build public confidence in vaccine safety, and reach the 22 million children who currently lack access to vaccines. As a doctor, an epidemiologist and a father, I know that childhood vaccination is a fundamental building block of health, and it gives me confidence to see that the treaty negotiators recognised that as well.
(1) The Lancet, Volume 379, Issue 9834, Page 2328, 23 June 2012
Running a health system with Mozambique’s staggering level of disease burden would challenge even the world’s richest nations. An estimated 13% of under-five deaths are caused by pneumonia, there are very high levels of malaria, and HIV creates another crushing burden with prevalence rates of more than 30 percent in some areas with resultant tuberculosis epidemics.
Yet Mozambique is not only one of the world’s poorest countries. Its poverty is compounded by the lasting impact of a 16-year civil war (1977-92) that severely disrupted health services, and recurrent floods that continue to undermine a fragile network of health centres.
This makes the Health Ministry’s efforts to put in place an effective and efficient immunisation system even more remarkable. During a recent three-day visit, I witnessed evidence of the Ministry’s success: from orderly vaccination sessions and the rigorous registration of immunisation cards at Manhiça district hospital, 70km from Maputo, to the well-trained personnel and cold chain system operating at the nearby Maragra health centre.
All of the clinics (albeit in a relatively high functioning area) that I visited took advantage of vaccination sessions to provide maternal and child health check-ups – a best practice long observed in developed countries. Far from having to convince mothers to vaccinate their children, I saw that immunisation is considered an important social occasion, with mothers dressing-up for a visit to the local clinic.
With the Health Ministry poised to introduce pneumococcal vaccine using GAVI support, there can be no room for complacency. Yet my visit also revealed some clear and present danger signs.
The Expanded Programme for Immunisation (EPI) group in Maputo confirmed that immunisation coverage rates for Mozambique dropped in 2010. This is borne out by an inability to lift pentavalent vaccine coverage to high-levels and an increase in measles outbreaks. Data shows that Mozambique is close to a full birth cohort of measles susceptibles; if there is a large outbreak, it will spread very quickly. Polio immunisation rates are disturbingly low which also means if there is a reintroduction, there is risk of a sizeable outbreak.
On the ground, local health centres explained to me the difficulties in running mobile immunisation clinics; essential to reach Mozambique’s often widely dispersed villages. In Manhiça district, the vehicle used for delivering vaccines to remote communities usually doubles-up as an ambulance – in emergencies, the mobile clinics can be cancelled at the last moment. There are also shortages of fuel and spare parts. And in more remote districts particularly in the North, this takes on a more concerning note: more than 40% of Mozambique’s citizens are not served by fixed based facilities, so for many, outreach is the norm.
Reassuringly, Mozambique’s Prime Minister Aires Ali told me that the national immunisation programme is a priority for his Government. Vice Health Minister Naira Abdula revealed her ambitious plans and that she has invited Mozambique’s Head of State to attend the launch of the pneumococcal vaccine, scheduled within the next two years.
There is also interest from the Health Ministry and GAVI’s in-country partners WHO and UNICEF in using GAVI’s health system strengthening support to meet the challenge of building a more sustainable vaccine delivery system.
The role of CSO’s in helping to solve these challenging problems has also been demonstrated. We observed Village Reach operating in Manhiça district, an NGO of which I am very familiar as I was a former board member. Village Reach has worked on vaccine delivery logistics in Mozambique for a number of years. They provide 4×4 vehicles to ensure there is no vaccine stock-out at local health centres, help to provide support for the cold chain as well as training health workers. You can learn more about this particular experience by visiting our website .
The challenge will be extending these kinds of collaborative solutions to Mozambique’s 127 other districts. Two decades after the end of the civil war, facilities and trained personnel remain in very short supply especially in the northern rural areas.
One of the most encouraging signs for Mozambique’s future is the full integration into the national health system of the Manhiça Foundation research facility. The centre is perhaps best known as one of 11 centres spread across seven African countries currently involved in phase III trials of the RTSS malaria vaccine candidate. However, the research facility is also doing trials of a new TB vaccine candidate and preparing for potential HIV vaccine trials. Moreover, their work goes far beyond vaccine trials. By following a large demographic cohort of >90,000 persons in the district (some of which dates back to 1996), they are providing real-time information on local disease burden and the on-going impact of public health interventions.
Furthermore, the Foundation is grooming a cadre of highly trained Mozambican scientists dedicated to improving people’s health in their country. Dr. Betuel Sigavque is one such example. Educated at Maputo’s medical school, Betuel joined the Manhiça Foundation in 2001, trained in Pediatrics and tropical medicine, and took his PHD in public health in Barcelona, Spain. Today, he doubles up as the Foundation’s director of research for pneumococcal vaccine research and for potential future HIV vaccine trails, and as the Chief Medical Officer at the Manhiça District hospital.
Thanks to the likes of Betuel and his many well trained colleagues at the Manhiça Foundation, as well as the Government’s vote of confidence in vaccines, I left Maputo with the sense that Mozambique’s immunisation system is likely to have a bright future. I and my colleagues at GAVI look forward to assisting Mozambique in any way that we can with this vision.
Leaders from many fields are gathering in Davos, Switzerland at the World Economic Forum. This is my seventh Davos meeting and it is always an exciting event. Particularly as I am now representing GAVI, which was born in Davos in 2000, and which like Davos brings together leaders from many fields, in the case of GAVI to save children’s lives and protect people’s health through immunisation.
The public-private partnership is part of the GAVI Alliance’s formula for success that has helped countries to immunise 325 million children in our first 10 years, saving more than 5.5 million lives. GAVI is about ensuring children in the poorest countries have access to the same vaccines as children in countries like Switzerland or the US. GAVI’s accomplishments are those of its alliance partners: UNICEF, the World Bank, WHO, the Bill & Melinda Gates Foundation, vaccine manufacturers, civil society organisations and governments all over the world.
This year’s WEF theme of “Great transformations: Shaping new models” could easily use the GAVI Alliance as a good example of how to use new models successfully. In fact, public-private partnerships are part of what brings me to Davos this week. I will be attending a breakfast meeting devoted to discussing a ground-breaking initiative called the GAVI Matching Fund.
The GAVI Matching Fund is an example of what can be achieved when governments, corporations, foundations and the general public work together to solve difficult problems.
They also are matching contributions made to GAVI by employees, customers, members and even business partners of those corporations and foundations. The goal – including the match – is to raise an additional US$ 260 million for immunisation by the end of 2015.
Vaccines are extremely cost-effective, giving kids a healthy start in life and supporting the economic and educational foundations of entire communities. They directly lead to a healthy workforce which is so critical to long-term development and prosperity for all countries.
A US$ 3 million donation – matched by the UK government or the Bill & Melinda Gates Foundation – buys enough vaccines to immunise more than 500,000 children against pneumococcal disease, one of the main causes of death from pneumonia. Or vaccinate nearly a million children against a potentially deadly form of diarrhoea caused by rotavirus.
These are among the vaccines being purchased under the GAVI Matching Fund through contriubutions made by, for instance, two of its partners: the “la Caixa” Foundation and Absolute Return for Kids (ARK)
The WEF calls on leaders like these to help set an inspiring vision to improve the world for future generations, to demonstrate personal courage that could reshape the global economy. It is the kind of foresight shown by the UK government in expanding its commitment to global development even during challenging economic times.
In fact, UK Secretary of State for International Development Andrew Mitchell MP will be at the GAVI Matching Fund breakfast meeting with me, along with a couple of dozen CEOs and board members from major global corporations, such as Anglo American and J.P. Morgan, each of which is a member of the GAVI Matching Fund.
We also will announce new members to the GAVI Matching Fund later this week at www.gavialliance.org, bringing us closer to ensuring that another 225 million children are immunised and an additional 3.9 million lives are saved over the next few years.
By bringing these new partners into the GAVI family we can not only diversity our funding base but also use the skills of these partners to help drive our mission.
The GAVI Matching Fund is only a few months old but it already has raised tens of millions of dollars for children’s immunisation.
That is the kind of public-private partnership that works and represents a rare chance to be part of something that will change the lives of millions of people for the better.
As 2011 draws to a close, it’s a good time to reflect on what an extraordinary year it’s been for GAVI and for this Alliance’s mission to ensure life-saving vaccines reach all the world’s children regardless of whether they are born in a poor country. Those of you who know me from my time as CEO of the International AIDS Vaccine Initiative will be familiar with my end of year letters and it’s a tradition I would like to introduce at GAVI.
Over the past five months, I have enjoyed getting to know better how the Alliance works: its members, its mechanisms and, most of all, the magical formula that ensures our partners deliver more together than alone. This learning process culminated in the recent GAVI Alliance Board meeting in Bangladesh, where it was great to see Geeta Rao Gupta, Deputy Executive Director at UNICEF and a leading champion of immunisation, appointed vice-Chair of the GAVI Board.
Without a doubt, the high point of the year was the June pledging conference in London when donor governments pledged funding which the Alliance will use to immunise close to a quarter of a billion children against life-threatening diseases by 2015. At a time when the economic outlook is uncertain, that represented an exceptional vote of confidence – not just in our Alliance but also the cost-effectiveness of vaccines and their ability to make a difference.
The level of political commitment was extraordinary. The Prime Ministers of the UK and of Norway, the President of Liberia, and Bill Gates and many many other leaders together brought the focus on immunisation to a whole new level. That political commitment came from implementing countries too, with the countries reaffirming their commitment to co-finance vaccines, which they continue to do. And in the approach to the conference, vaccine manufacturers made offers of significant price reductions for key vaccines.
As the chair of the GAVI Board, Dagfinn Høybråten, said recently, it was a great GAVI moment; and we need more moments like that.
Prior to the conference, pneumococcal vaccines were already reaching developing countries in record time thanks to GAVI support; in February, Kenya’s President, Mwai Kbaki, marked the introduction of pneumococcal vaccines into the national immunisation programme with a special event to celebrate the global rollout. Now, the pledging conference has given us an enormous opportunity to accelerate the rollout of both pneumococcal and rotavirus vaccines against the leading causes of pneumonia and diarrhoea deaths respectively. By 2015, some 40 countries are expected to gain access to these vaccines through GAVI funding and the work of countries and our other partners in countries.
We recognise that a number of countries eligible for GAVI support do not have the immunisation infrastructure in place to deliver all of the new antigens. Funding the introduction of new vaccines is only part of GAVI’s vision. Immunisation programmes also need to be sustainable so vaccines do not protect only one birth cohort. Working with our partners on the ground to build countries’ systems and figure out their needs will be a critical part of what we have to do in the immediate future.
As an innovative Alliance, GAVI never stands still and, last month, we were pleased that our Board meeting in Bangladesh took the first steps to opening windows of support for the introduction of vaccines against human papillomavirus (HPV) - the second human cancer vaccine - and rubella virus in developing countries. Both have a huge potential impact. If negotiations to secure a sustainable price for the vaccine from manufacturers are successful and countries can demonstrate their ability to deliver them, up to two million women and girls in nine countries could be protected from cervical cancer by 2015. Over the same period, the rubella vaccine has the potential to reach 588 million children.
Opening an HPV window does bring its own set of new challenges. While we will be able to build on the same cold chain used for other vaccines, the vaccine needs to be provided to adolescent girls, which is a new age group for GAVI.
However, our Alliance allows us to bring together an enormous number of talented people to accomplish more than our individual capacities alone. In 2012, we will be looking to build new partnerships with reproductive health groups, family planning groups, ministries of education, nutrition and maternal child health and others, and these will help to provide opportunities to link the introduction of HPV vaccine with other additional steps to improve girls’ and families’ health.
If we lift our eyes to the horizon, there are many new opportunities in prospect. The research and development effort on vaccines is currently very rich. In 2011, phase three trials of a malaria vaccine delivered exciting early data. And in addition to the traditional multinational pharmaceutical companies, there is the R&D work being done by Public-Private Product Development Partnerships as well as the beginnings of work being done by developing country manufacturers.
The Alliance needs to be a big tent where all of the major players in immunisation can meet. So we need to rethink our links to the polio eradication campaign, which is continuing to have success and is beginning to think about the end game for this terrible scourge of mankind. Similarly we need to look at how we can strengthen our connection with those working on measles elimination. Our work here is aligned with and part of the Decade of Vaccines and our goal of ensuring vaccines are a higher public health priority.
As I noted above, we received significant new commitments from vaccine manufacturers on prices in the approach to the pledging conference. We need to continue to work to create a healthy vaccine market, with secure supply, as much competition as possible, assurance of high quality and sustainable prices. Under our new supply and procurement strategy, approved at the November Board meeting, we will look at each vaccine market in turn and take a tailored approach to each.
With these challenges ahead, and the success of the June replenishment notwithstanding, it is critical that GAVI constantly thinks about how to renew resources and diversify its funding base, especially in the current economic climate. We were delighted this year to have two donor governments, Brazil and Japan, make their first grants to GAVI. The Matching Fund initiative, launched by the UK and the Gates Foundation, is also attracting new private sector champions to our cause.
Such generosity puts the emphasis on being accountable to our donors. Last month’s Aid Effectiveness conference, which I attended in Busan, South Korea, emphasised the importance of data transparency. In 2011, GAVI published all its key performance indicators on www.gavialliance.org. In 2012, we will strive to improve immunisation impact data by working with our partners and also give access to more timely information on vaccine rollouts.
Finally, I take inspiration from the memory of a Dhaka schoolgirl Saleha Akhter, presentor of a video shown to the GAVI Board last November and a reminder of why GAVI exists.
In six significant minutes, Saleha describes the vital role of governments, UN agencies, civil society organisations, vaccine manufacturers and donors in delivering vaccines to her fellow Bangladeshi schoolchildren. All are critical members of our extended family. Without these combined talents, neither Saleha nor 90% of her fellow Bangladeshi schoolchildren might ever have had the chance to fulfill their life’s potential.
As always, we thank you for your interest in GAVI’s work and look forward to working with you next year to continue to increase our impact on the lives of so many. If there are any questions, please let us know.
With best wishes for you and yours for the holiday season.
My British friends sometimes refer to pneumonia as “old man’s friend”, because it can bring swift and painless death to elderly patients who become unconscious and slip away in their sleep.
But 98.5 percent of pneumonia deaths actually happen in the developing world and pneumonia is not a friend.
In fact pneumonia is the world’s biggest killer of children, filling their little lungs until breathing becomes difficult and painful. It kills 1.5 million children under five every year.
But as we observed World Pneumonia Day this year on Saturday 12 November, we celebrated the fact that vaccines against pneumococcal disease, the biggest cause of pneumonia, are finally reaching the children that need them most.
Almost a year ago, in December 2010, Nicaragua became the first of 15 developing countries so far to have introduced the pneumococcal vaccine. By the end of next year, 13.6 million children in developing countries will have been immunised against the leading cause of pneumonia.
The idea that vaccines can save lives is not a new idea, of course. In the last 30 years or so, immunisation has brought profound drops in the incidence of many diseases, including measles, polio, and tetanus. It has also eradicated smallpox.
As the CEO of the GAVI Alliance, a public-private partnership focused on saving children’s lives by increasing access to immunisation in poor countries, I’m proud to say that – with magnificent support from the British government – we have made available these pneumococcal vaccines to children in the world’s poorest countries.
By concluding long-term supply agreements, our Advance Market Commitment (AMC) has reduced market uncertainty, encouraging manufacturers to develop adequate production capacity and to supply at drastically lower prices.
By some estimates these vaccines are now reaching developing countries about 10 to 15 years earlier than they would otherwise have done.
Breast-feeding, better nutrition, and antibiotics are also key to reducing the burden of pneumonia deaths in the developing world.
But when isolation and lack of resources mean medical care is hard to access, immunisation becomes even more important. GAVI also supports vaccines against Hib, measles, and whooping cough, which help reduce the pneumonia burden.
The pneumococcal vaccines alone could save as many as 7 million child lives by 2030.
Like the other vaccines that we support, pneumococcal vaccines help save lives and protect the health of communities. And by protecting families from disease and disability, we are also saving them the costs of expensive medical care and treatment, preventing many of them from sliding deeper into poverty.
In our first decade of work, GAVI has helped countries immunise nearly 300 million children so far. And the British government’s US$ 2.5 billion contributions to GAVI equal about a third of our total income.
My British friends and I agree: no child should die of a disease we can prevent.