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As the end of the year approaches, I would like to reflect on my recent trip to Lao People’s Democratic Republic (Lao PDR) for a very lively and productive Board meeting. The country is in many ways a success story: with Gavi’s assistance, immunisation coverage has gone from 50% in 2007 to 82% today, and six new vaccines have been introduced in the same period.
Lao PDR is also in the midst of preparing to transition out of our support. I was happy to get to see some of this work first-hand, including a project aimed at replacing a paper-based health management system with a modern, web-based, open source reporting system. This is precisely the kind of approach needed to plug the data gaps to maintain high levels of vaccination beyond 2021, when Lao is due to transition.
This kind of technological innovation is becoming an increasingly important part of our mission. In 2017 alone we saw three big technology pushes. The first, Gavi’s Innovation for Uptake and Scale and Equity in Immunisation, or INFUSE, seeks to bridge the gap between vaccine delivery innovators and implementing countries. This year, INFUSE took the first steps towards implementation in countries. For example, Nexleaf’s low-cost remote temperature monitoring devices moved beyond India and started to be installed in health centres across Tanzania, Kenya and Mozambique. Through its partnership with Google, Nexleaf can provide real-time data on the performance of vaccine refrigerators through the cloud. The second push was our technology forum in Silicon Valley, where we met with leaders from the business community, philanthropic organisations, venture funds and academia to discuss how technology can be used to help Gavi meet its global health priorities.
Gavi’s Cold Chain Equipment Optimisation Platform, designed to stimulate supply and innovation of the equipment used to keep vaccines cool during their long journey, also really took off this year. 2017 saw countries apply for 62,000 pieces of new and environmentally friendly equipment, such as solar-powered fridges. More than a quarter of these were for previously unequipped facilities, thus expanding reach and helping to improve coverage and equity.
There will always be challenging exceptions, of course. In 2017, the ongoing conflicts in Syria and Yemen served as reminder of why we need to be flexible when dealing with fragile states, and ensure that children’s lives always come first. This also applies to our use of emergency stockpiles , which were put to the test in different ways during the year. Gavi-supported doses of cholera vaccine were used in Yemen and Sierra Leone (following one of Africa’s worst mudslides), as well as among Rohingya refugees in Cox’s Bazar, while yellow fever vaccine doses were provided to Brazil and Angola. The emergency supply of Ebola vaccine that we have helped to make available was nearly called upon following a brief but worrying Ebola flare up in the Democratic Republic of the Congo.
We are also facing challenges with regards to human papillomavirus (HPV) and polio vaccines. Unprecedented demand from countries for HPV vaccine has led to serious supply shortages. This is all the more frustrating given that countries were ready to dramatically increase coverage and create herd immunity by making the vaccine available to full multi-year cohorts of girls in primary school. We are working closely with vaccine manufacturers and other Alliance partners to improve the health of the HPV vaccine market and plan more effectively for the future.
With polio vaccine, it’s a question of coverage. We are so close to eradicating polio, but at the same time we’re seeing alarmingly low immunisation coverage in countries that have already eliminated this devastating disease. The latest data shows that in 39 countries coverage with the third dose of oral polio vaccine is less than 85%, while 16 countries report coverage below 75%.
In Nigeria, one of the three countries that are still polio endemic, national coverage is less than 50%. In the other two, Pakistan and Afghanistan, there are still pockets where coverage is below 50%. To change this, and to protect against potential outbreaks, we will need to concentrate efforts to boost routine immunisation.
Despite these challenges, the Alliance has been making very positive progress. Thanks to the Advance Market Commitment (AMC) for pneumococcal vaccines, 109 million children have been protected against the most common cause of pneumonia – leading to half a million prevented deaths. During the year we also saw India, the second most populous country in the world, introduce the pneumococcal vaccine. As India launches the vaccine nationally, along with the recently introduced rotavirus vaccine, it can prevent as many as 90,000 deaths and generate economic benefits worth US$ 1 billion every year.
Another good news story is measles, a disease that used to kill 2.6 million people a year in the 1980s, before widespread vaccination. For the first time in history, the number of people dying from this terrible disease has dropped below 100,000 per year – principally because of vaccination. Since 2000, 5.5 billion doses have been given to children through routine immunisation and mass vaccination campaigns.
Sadly, this excellent progress threatens to be undermined by low coverage – not only in many developing countries but also in some wealthy countries. Some of the largest outbreaks of measles witnessed during the year were in OECD countries such as Italy and Germany. Because measles is so infectious, a much higher level of vaccination coverage is required to achieve herd immunity than for other vaccines. As a result, measles outbreaks can pinpoint areas of low immunisation coverage at an early stage.
This highlights the importance of working with countries and our partners to map areas of low coverage and channel resources in order to reach every child. We have taken great strides to strengthen our Alliance by improving the way in which the partners work together and with countries to boost immunisation coverage and equity. Following the first full year of the partners’ engagement framework (PEF), which puts the country’s immunisation programme in the driving seat of technical assistance, our partners WHO and UNICEF now have more than 200 full-time country office staff funded by PEF, giving us more possibilities to provide capacity building.
Gavi’s efforts to reach the last mile and improve coverage and equity are at the heart of the universal health coverage (UHC) movement that Dr Tedros Adhanom Ghebreyesus, WHO’s new Director-General, is prioritising. I’m just back from a very successful UHC conference in Tokyo, where I spoke about the role of immunisation in achieving UHC together with Prime Minister Shinzo Abe and leaders of other global health organisations.
Assuring that every child has access to vaccines will take us a step closer to the Sustainable Development Goal (SDG) targets. We were very pleased that UN member states approved an ambitious set of measures to track immunisation progress under the SDGs. These encompass a range of vaccines, from the traditional diphtheria-tetanus-pertussis vaccine and a second dose of measles vaccine through to the HPV vaccine, which is given to adolescent girls, and the new pneumococcal vaccine.
The really great news is the response we are seeing to these goals from the countries we support. 35 new vaccine launches have taken place this year and more than half a billion vaccine doses have been administered. At the African Union Summit in February we witnessed an historic commitment made by African Heads of State in endorsing the Addis Declaration on Immunization. This was not limited to increasing access to immunisation – countries also expressed their commitment to investing in their vaccine programmes. Country co-financing for 2017 is estimated at a record US$ 160 million.
Donors are also stepping up: this year saw the highest level of support to date. We are delighted that Denmark has announced plans to return as a Gavi donor and that India has decided to extend its pledge for another four years. We are also pleased that Sweden, the Republic of Korea, the United Arab Emirates and Canada have provided additional funding. Donors’ continued confidence was further illustrated by high marks in reviews by both the Multilateral Organization Performance Assessment Network (MOPAN) and the UK.
With 21 countries expected to have transitioned out of our support by the end of 2020, the Board in November reaffirmed its commitment to engaging closely with countries during this process. It also agreed to continue to work with countries post transition to ensure they can sustain high immunisation coverage levels. To this end, the Board approved US$ 30 million for technical assistance until 2020.
The Board also approved support for a new typhoid conjugate vaccine, which protects against a disease that currently infects nearly 12 million people and kills close to 130,000 every year. Given that the vaccine, which we expect to be prequalified soon, can be given to children under the age of two it can be incorporated into routine immunisation schedules – creating the potential for high coverage. Widespread use of the vaccine will not only have an impact on reducing typhoid fatalities but also help in the fight against antimicrobial resistance.
Finally, I would like to say how delighted I am that Dr Ngozi Okonjo-Iweala will continue to serve as our Board Chair for another three years. In July, the Board unanimously reappointed Dr Ngozi, following her leadership and engagement with countries and partners, and reappointed me as CEO for a further four years.
All of this stands us in good stead for the year to come – a year which will see the first large-scale pilots of the RTS,S malaria vaccine, Gavi’s mid-term review and our relocation to the new Global Health Campus. With that in mind, please let me wish you a very happy and restful holiday season. I look forward to engaging with you in the year to come.
Seth Berkley
CEO of Gavi, the Vaccine Alliance