Health Affairs Special Issue: Strategies For The ‘Decade Of Vaccines’

Health Affairs
June 2011; Volume 30, Issue 6
Strategies For The ‘Decade Of Vaccines’

From The Editor-in-Chief
Vaccines, Children, And Fulfilling Human Potential
Susan Dentzer
Health Aff June 2011 30:1006; doi:10.1377/hlthaff.2011.0562

Entry Point
Slow Going For The Global Health Initiative
Nellie Bristol
Health Aff June 2011 30:1007-1009; doi:10.1377/hlthaff.2011.0460
The program of US foreign assistance to advance health and health care in developing countries survived the 2011 budget battles, but it continues to face other challenges.

The Priceless Payoff
During The ‘Decade Of Vaccines,’ The Lives Of 6.4 Million Children Valued At $231 Billion Could Be Saved
Sachiko Ozawa, Meghan L. Stack, David M. Bishai, Andrew Mirelman, Ingrid K. Friberg, Louis Niessen, Damian G. Walker, and Orin S. Levine
Health Aff June 2011 30:1010-1020; doi:10.1377/hlthaff.2011.0381
Governments constantly face the challenge of determining how much they should spend to prevent premature deaths and suffering in their populations. In this article we explore the benefits of expanding the delivery of life-saving vaccines in seventy-two low- and middle-income countries, which we estimate would prevent the deaths of 6.4 million children between 2011 and 2020. We present the economic benefits of vaccines by using a “value of statistical life” approach, which is based on individuals’ perceptions regarding the trade-off between income and increased risk of mortality. Our analysis shows that the vaccine expansion described above corresponds to $231 billion (uncertainty range: $116–$614 billion) in the value of statistical lives saved. This analysis complements results from analyses based on other techniques and is the first of its kind for immunizations in the world’s poorest countries. It highlights the major economic benefits made possible by improving vaccine coverage.

Estimated Economic Benefits During The ‘Decade Of Vaccines’ Include Treatment Savings, Gains In Labor Productivity
Meghan L. Stack, Sachiko Ozawa, David M. Bishai, Andrew Mirelman, Yvonne Tam, Louis Niessen, Damian G. Walker, and Orin S. Levine
Health Aff June 2011 30:1021-1028; doi:10.1377/hlthaff.2011.0382
In 2010 the Bill & Melinda Gates Foundation announced a $10 billion commitment over the next ten years to increase access to childhood vaccines in the world’s poorest countries. The effort was labeled the “Decade of Vaccines.” This study estimates both the short- and long-term economic benefits from the introduction and increased use of six vaccines in seventy-two of the world’s poorest countries from 2011 to 2020. Increased rates of vaccination against pneumococcal and Haemophilus influenzae type b pneumonia and meningitis, rotavirus, pertussis, measles, and malaria over the next ten years would save 6.4 million lives and avert 426 million cases of illness, $6.2 billion in treatment costs, and $145 billion in productivity losses. Monetary estimates based on this type of analysis can be used to determine the return on investment in immunization from both the international community and local governments, and they should be considered in policy making.

ANALYSIS & COMMENTARY: The Moral Case For The Routine Vaccination Of Children In Developed And Developing Countries
Angus Dawson
Health Aff June 2011 30:1029-1033; doi:10.1377/hlthaff.2011.0301
In developed countries some parents have decided not to provide routine vaccinations for their children, while in many developing countries there are inadequate rates of vaccination for various reasons. The consequences for children, and members of the community in which they live, can be significant and even tragic. Although some parents may worry that vaccines will harm their child, there is a broader moral case for vaccination that parents and policy makers should consider. This case has four components: benefits and harms, best interests, community benefits, and justice. This moral case should be central to deliberations about vaccination by parents and policy makers.

Challenges For Science & Business
ANALYSIS & COMMENTARY: A Global Road Map Is Needed For Vaccine Research, Development, And Deployment
Adel Mahmoud
Health Aff June 2011 30:1034-1041; doi:10.1377/hlthaff.2011.0391
The world is witnessing a tremendous interest in the discovery, development, and use of vaccines as an important contributor to disease prevention and control. However, current global vaccine efforts are not coordinated, and they face many challenges. One is scientific: Most vaccines in use today are based on the scientific knowledge of past centuries. To usher in a new era, there is an urgent need to draw upon new science and scientific disciplines and recruit a new generation of talent trained in the basic and computational sciences of the twenty-first century. In addition, a global road map is urgently needed for making the scientific discoveries necessary to produce new vaccines; developing these into effective vaccines; and drawing up priorities and undertaking the necessary planning for rolling out these vaccines in developing countries. The developing countries themselves must play the lead role in these activities and contribute their own resources as well. This article aims to initiate a wide-ranging debate and discussion that will ultimately result in some agreement on the future of vaccine development and deployment.

ANALYSIS & COMMENTARY: Vaccines As A Global Imperative—A Business Perspective
Jean Stéphenne
Health Aff June 2011 30:1042-1048; doi:10.1377/hlthaff.2011.0338
During the past thirty years, vaccines have experienced a renaissance. Advances in science, business, and distribution have transformed the field to the point where vaccines are recognized as a “best buy” in global health, a driver of pharmaceutical industry growth, and a key instrument of international development. With many new vaccines available and others on the horizon, the global community will need to explore new ways of ensuring access to vaccines in developing nations. So-called tiered pricing, which makes vaccines available at different prices for countries at different levels of economic development; innovative financing mechanisms such as advance market commitments or offers of long-term and high-volume contracts to vaccine producers; and technology transfers such as sharing intellectual property and production techniques among companies and countries can all play a part in bringing new life-saving vaccines for pneumonia, rotavirus, malaria, and other diseases to developing countries.

Fighting Critical Diseases
Eliminating Epidemic Group A Meningococcal Meningitis In Africa Through A New Vaccine
F. Marc LaForce and Jean-Marie Okwo-Bele
Health Aff June 2011 30:1049-1057; doi:10.1377/hlthaff.2011.0328
A new affordable vaccine against Group A meningococcus, the most common cause of large and often fatal African epidemics of meningitis, was introduced in Burkina Faso, Mali, and Niger in 2010. Widespread use of the vaccine throughout much of Africa may prevent more than a million cases of meningitis over the next decade. The new vaccine is expected to be cost-saving when compared to current expenditures on these epidemics; for example, an analysis shows that introducing it in seven highly endemic countries could save $350 million or more over a decade. International donors have already committed funds to support the new vaccine’s introduction in Burkina Faso, Niger, and Mali, but an estimated US$400 million is needed to fund mass immunization campaigns in people ages 1–29 over six years in all twenty-five countries of the African meningitis belt. The vaccine’s low cost—less than fifty cents per dose—makes it possible for the affected countries themselves to purchase vaccines for future birth cohorts.

ANALYSIS & COMMENTARY: Product Development Partnerships Hit Their Stride: Lessons From Developing A Meningitis Vaccine For Africa
David M. Bishai, Claire Champion, Michael E. Steele, and Lindsay Thompson
Health Aff June 2011 30:1058-1064; doi:10.1377/hlthaff.2011.0295
The Meningitis Vaccine Project, a so-called product development partnership, developed a new vaccine against bacterial meningitis, an inflammation of brain tissues that causes an estimated 10,000 deaths among African children and young people each year. The vaccine—known as MenAfriVac and specifically targeted for use in low-income countries in Africa—was designed to be made available to governments at a price of fifty cents per dose. The Meningitis Vaccine Project is an example of how product development partnerships have reinvigorated research on vaccines for neglected diseases. These partnerships disperse the multiple tasks of product development across a network of partners that are best suited for each task. The vaccine was rapidly embraced by African health officials, and in its first few weeks on the market, in late 2010, more than nineteen million people in Burkina Faso, Mali, and Niger were vaccinated.

Producing A Successful Malaria Vaccine: Innovation In The Lab And Beyond
Christian Loucq, Ashley Birkett, David Poland, Carla Botting, Julia Nunes, and Sally Ethelston
Health Aff June 2011 30:1065-1072; doi:10.1377/hlthaff.2011.0356
With approximately 225 million new cases and 800,000 deaths annually, malaria exacts a tremendous toll—mostly on African children under the age of five. Late-stage trials of an advanced malaria vaccine candidate—which, if approved, would become the world’s first malaria vaccine—are under way, and it may be ready for use by 2015. This article recounts the pivotal roles in that achievement played by collaborations of nonprofit organizations, pharmaceutical companies, private and public donors, and countries whose citizens would benefit most directly from a vaccine. Just as it takes a village to raise a child, it has taken a huge number of stakeholders around the world to reach this point. Developing even more effective vaccines for malaria and other diseases will require continued hard work and creative thinking from scientists, regulators, and policy makers.

The Challenges Of Developing New Tuberculosis Vaccines
Lewellys F. Barker, Annmarie E. Leadman, and Bartholt Clagett
Health Aff June 2011 30:1073-1079; doi:10.1377/hlthaff.2011.0303
The World Health Organization estimates that tuberculosis is causing nearly two million deaths annually, mostly in developing countries. Widespread administration of the current tuberculosis vaccine to newborns is not a reliable route for preventing the disease in adults, the population that drives the epidemic. Several new vaccine candidates are in development, and a few have entered clinical trials. However, the field faces formidable scientific and policy challenges. A collaborative approach to solving scientific, policy, and resource obstacles—as well as new partnerships among emerging economies and vaccine development organizations—will be critical to developing a new tuberculosis vaccine that could achieve its public health potential to save lives and reduce the burden of disease.

A Handful Of ‘Antipoverty’ Vaccines Exist For Neglected Diseases, But The World’s Poorest Billion People Need More
Peter Hotez
Health Aff June 2011 30:1080-1087; doi:10.1377/hlthaff.2011.0317
So-called neglected tropical diseases are the most common infections of the world’s poor. Almost all of the “bottom billion”—the 1.4 billion people who live below the poverty level defined by the World Bank—suffer from one or more neglected diseases including hookworm infection, sleeping sickness, or Chagas disease. These diseases are actually a cause of poverty because of their adverse effects on child growth and development and worker productivity. Vaccines to combat such diseases have come to be known as “antipoverty vaccines.” Unfortunately, the recent surge in the development and delivery of vaccines to combat the major childhood killers—such as pneumococcal pneumonia and measles—has bypassed neglected diseases. Nevertheless, some vaccines for these neglected diseases are now entering the clinical pipeline. In this article I describe how some antipoverty vaccine development is proceeding and offer recommendations for stimulating further development such as through pooled funding for innovation, developing-country manufacturers, and public-private partnerships for product development.

Providing Vaccines Against Human Papillomavirus To Adolescent Girls In The Americas: Battling Cervical Cancer, Improving Overall Health
Silvana Luciani, Elisa Prieto-Lara, and Andrea Vicari
Health Aff June 2011 30:1089-1095; doi:10.1377/hlthaff.2011.0315
Vaccines against the human papillomavirus (HPV)—the primary cause of cervical cancer—target adolescent girls, many of whom have limited contact with health services. Countries in the Americas are beginning to use HPV vaccines to increase the impact of cervical cancer programs and as an entry point to broader health services for girls. This strategy opens new opportunities to improve lifelong health habits; encourage regular cervical cancer screening and treatment, when necessary; and offer associated services such as reproductive health and nutrition guidance. Some of the early experiences with this strategy illustrate challenges and opportunities that may arise with other new vaccines.

People & Places
Health Aff June 2011 30:1088; doi:10.1377/hlthaff.2011.0513
Peter Hotez and his Sabin Vaccine Institute seek to end preventable illness among the world’s impoverished people.

Strengthening Programs
India’s Vaccine Deficit: Why More Than Half Of Indian Children Are Not Fully Immunized, And What Can—And Should—Be Done
Ramanan Laxminarayan and Nirmal Kumar Ganguly
Health Aff June 2011 30:1096-1103; doi:10.1377/hlthaff.2011.0405
Although India is a leading producer and exporter of vaccines, the country is home to one-third of the world’s unimmunized children. Fewer than 44 percent of India’s young children receive the full schedule of immunizations. India’s vaccine deficit has several causes: little investment by the government; a focus on polio eradication at the expense of other immunizations; and low demand as a consequence of a poorly educated population and the presence of anti-vaccine advocates. In this article we describe India’s vaccine deficit and recommend that the government move quickly to increase spending on, and otherwise strengthen, national immunization programs.

ANALYSIS & COMMENTARY: Challenges To Building Capacity For Evidence-Based New Vaccine Policy In Developing Countries
Jon Kim Andrus, Barbara Jauregui, Lúcia Helena De Oliveira, and Cuauhtémoc Ruiz Matus
Health Aff June 2011 30:1104-1112; doi:10.1377/hlthaff.2011.0361
There are many challenges to ensuring that people in developing countries have equitable access to new vaccines. Two of the most important are having the capacity to make evidence-based new vaccine policy decisions in developing countries, and then when appropriate actually distributing those new vaccines to those who will most benefit from them. Based on our review of the Pan American Health Organization’s ProVac Initiative in the Americas, we found that when national governments in developing countries develop the expertise to make the best technical decisions about immunization programs; take responsibility for helping to pay for and distribute vaccines; and are supported by strong partnerships with international organizations, they succeed in saving more lives more quickly.

ANALYSIS & COMMENTARY: Vaccine Supply Chains Need To Be Better Funded And Strengthened, Or Lives Will Be At Risk
Judith R. Kaufmann, Roger Miller, and James Cheyne
Health Aff June 2011 30:1113-1121; doi:10.1377/hlthaff.2011.0368
In the next decade, at least twelve additional vaccines that target such diseases as typhoid, malaria, and dengue will become available to lower- and middle-income countries. These vaccines must travel along what are called supply chains, which include all personnel, systems, equipment, and activities involved in ensuring that vaccines are effectively delivered from the point of production to the people who need them. But for various reasons, supply chains are already strained in many developing countries, and the potential inability to distribute new vaccines will place lives at risk. Among the many steps needed to strengthen the global vaccine supply chain, we suggest that the international community pursue improved coordination between organizations that donate and ship vaccines and the host-country officials who receive and distribute the vaccines, as well as better training for supply-chain managers.

An Analysis Of How The GAVI Alliance And Low- And Middle-Income Countries Can Share Costs Of New Vaccines
Helen Saxenian, Santiago Cornejo, Kira Thorien, Robert Hecht, and Nina Schwalbe
Health Aff June 2011 30:1122-1133; doi:10.1377/hlthaff.2011.0332
Immunization is one of the “best buys” in global health. However, for the poorest countries, even modest expenditures may be out of reach. The GAVI Alliance is a public-private partnership created to help the poorest countries introduce new vaccines. Since 2008 GAVI has required that countries cover a share of the cost of vaccines introduced with GAVI support. To determine how much countries can contribute to the cost of vaccines—without displacing spending on other essential programs—we analyzed their fiscal capacity to contribute to the purchase of vaccines over the coming decade. For low-income countries, external financing will be required to purchase vaccines supported by GAVI, so co-financing needs to be modest. Relatively better-off “intermediate” countries could support initially modest but gradually increasing co-financing levels. The countries soon to graduate from GAVI can generally afford to follow a rapid path to self-sufficiency. Co-financing for these countries needs to ramp up so that national budgets fully cover the costs of the new generation of vaccines once GAVI support ends.

Creating Sustainable Financing And Support For Immunization Programs In Fifteen Developing Countries
Michael McQuestion, Devendra Gnawali, Clifford Kamara, Helene Mambu-Ma-Disu, Jonas Mbwangue, and Ciro de Quadros
Health Aff June 2011 30:1134-1140; doi:10.1377/hlthaff.2011.0265
Immunization programs are important tools for reducing child mortality, and they need to be in place for each new generation. However, most national immunization programs in developing countries are financially and organizationally weak, in part because they depend heavily on funding from foreign sources. Through its Sustainable Immunization Financing Program, launched in 2007, the Sabin Vaccine Institute is working with fifteen African and Asian countries to establish stable internal funding for their immunization programs. The Sabin program advocates strengthening immunization programs through budget reforms, decentralization, and legislation. Six of the fifteen countries have increased their national immunization budgets, and nine are preparing legislation to finance immunization sustainably. Lessons from this work with immunization programs may be applicable in other countries as well as to other health programs.

Issues For The United States
The Benefits To All Of Ensuring Equal And Timely Access To Influenza Vaccines In Poor Communities
Bruce Y. Lee, Shawn T. Brown, Rachel R. Bailey, Richard K. Zimmerman, Margaret A. Potter, Sarah M. McGlone, Philip C. Cooley, John J. Grefenstette, Shanta M. Zimmer,
William D. Wheaton, Sandra Crouse Quinn, Ronald E. Voorhees, and Donald S. Burke
Health Aff June 2011 30:1141-1150; doi:10.1377/hlthaff.2010.0778
When influenza vaccines are in short supply, allocating vaccines equitably among different jurisdictions can be challenging. But justice is not the only reason to ensure that poorer counties have the same access to influenza vaccines as do wealthier ones. Using a detailed computer simulation model of the Washington, D.C., metropolitan region, we found that limiting or delaying vaccination of residents of poorer counties could raise the total number of influenza infections and the number of new infections per day at the peak of an epidemic throughout the region—even in the wealthier counties that had received more timely and abundant vaccine access. Among other underlying reasons, poorer counties tend to have high-density populations and more children and other higher-risk people per household, resulting in more interactions and both increased transmission of influenza and greater risk for worse influenza outcomes. Thus, policy makers across the country, in poor and wealthy areas alike, have an incentive to ensure that poorer residents have equal access to vaccines.

Confidence About Vaccines In The United States: Understanding Parents’ Perceptions
Allison Kennedy, Katherine LaVail, Glen Nowak, Michelle Basket, and Sarah Landry
Health Aff June 2011 30:1151-1159; doi:10.1377/hlthaff.2011.0396
The United States has made tremendous progress in using vaccines to prevent serious, often infectious, diseases. But concerns about such issues as vaccines’ safety and the increasing complexity of immunization schedules have fostered doubts about the necessity of vaccinations. We investigated parents’ confidence in childhood vaccines by reviewing recent survey data. We found that most parents—even those whose children receive all of the recommended vaccines—have questions, concerns, or misperceptions about them. We suggest ways to give parents the information they need and to keep the US national vaccination program a success.