We hear it time and again. The locations change, as do some of the details, but many of the stories told by MSF staff providing basic vaccinations to children have striking similarities: A mother arrives having traveled a great distance—usually on foot—from a remote village. Driven by a purpose beyond herself, she has carried her child or children across rivers or mountains or frontlines because she had heard that someone was vaccinating children against diseases that continue to kill infants the world over, and she wanted to make sure that hers—or as many of them as she could bring—got the protection they needed.
It’s not the only time she’ll have to make the journey, however; the full course of vaccinations requires five visits during the first year of a child’s life. So before long, she’ll likely be doing it all again.
Through their actions, mothers like these provide more compelling evidence of the need for wider access to vaccinations than any statistic could. Still, the numbers are telling, one set of them in particular: Every year, some 22 million children do not get the vaccines they need—that’s five times more than the total number of children born annually in the United States—and roughly 70 percent of them live in 10 countries.
Working to Expand Access
Vaccines have long been part of the services MSF offers, particularly in countries where vaccine coverage is low. As part of basic health care programs in these places, teams provide children with a slate of vaccines currently recommended by the World Health Organization: DTP (diphtheria, tetanus, pertussis), hepatitis B, Haemophilius influenzae type b (Hib), BCG (against tuberculosis), measles, polio, and, increasingly, pneumococcal conjugate vaccine.
Other organizations like the Gates Foundation and the GAVI Alliance (formerly known as the Global Alliance for Vaccines and Immunization) also focus on vaccinating children and getting the newest vaccines to developing countries. And real progress has been made. But all involved know that much could be improved, that more children could, and must, be reached.
Led by its Access Campaign, MSF has identified some specific issues that prevent our teams and others involved in this effort from reaching as many children as they could. While our logisticians work to get drugs where they need to be and field staff work to identify children in need in places that are too often overlooked by national health plans and aid organizations, the Access team will continue pushing for policy and research and development reforms that can make more vaccinations available, at lower cost, for more people.
A Need for Adaptability
One reason mothers have to travel so far to get vaccines for their children is because in many cases, it’s simply not possible to bring the vaccines to them. As constituted at present, these vaccines have storage and delivery requirements that can be very difficult to uphold.
Imagine trying to reach children in a remote village in, say, India, or Chad, or Central African Republic. The roads are bad, prone to flooding during the rainy season. The vaccines themselves need to be keptat a certain temperature—between 2° to 8° Celsius, or roughly 35° to 46° Fahrenheit—lest they become ineffective, but there’s no electricity along much of the route. And the vaccines mostly have to be administered with needles by trained health professionals, people who are often in short supply in countries lagging in terms of development or afflicted by years of conflict.
MSF teams must contend with all of these challenges, and not all of them can be surmounted with existing technology. There is a profound need for vaccines that are better adapted to the settings in which they will be used. If they could withstand higher temperatures, if they could be delivered through a mist or a patch, or if the course could be completed with fewer doses, it would be far more feasible to get the vaccines and people who could administer them to the towns in which these mothers and children live—rather than putting the onus on them to come to fixed medical sites, and in some cases, make a brutal choice about which children they can take with them.
MSF’s position is that the global vaccination community, led by the WHO, UNICEF, the GAVI Alliance, and the Gates Foundation, and working with governments in developing countries, needs to emphasize and help enable the development of better-adapted vaccines. Rather than sticking with a one-size-fits-all approach, vaccines should be tailored to specific contexts, specific countries, and specific strains of a given disease.
In 2001, the cost to provide a child with basic vaccinations was $1.38. Today, it’s $38.80, an increase of more than 2,700 percent. Given the fact that the number of basic antigens recommended by the WHO has climbed from 6 to 11, the price was certain to rise. But the jump is largely attributable to the high price of new vaccines—particularly those for rotavirus and pneumococcal disease, which together make up more than 70 percent of the price tag—resulting in a cost structure that is simply not sustainable for many countries.
It’s hard to criticize vaccines that cover children against more diseases. But if prices stay high, fewer vaccines are bought and administered, so fewer children get vaccinated. As one Ministry of Health official in Kenya put it, “Adding new, expensive vaccines to the national immunization program” without somehow accounting for the price increase “is like taking out multiple mortgages.”
GAVI has committed almost $8 billion dollars to introduce new vaccines and strengthen existing immunization systems in the developing world, and as the largest purchaser of vaccines for poorer countries, the organization can negotiate more favorable terms for countriesit covers. But once a country’s annual per capita income rises above $1,550, that country begins to “graduate” and move out from under the GAVI umbrella, into terrain where they’ll be forced to pay incrementally more in the years that follow.
By 2016, for instance, some 17 countries will have lost GAVI support, and more countries are starting the “graduation” process each year. No longer eligible for reduced prices, countries like Republic of Congo and Honduras may soon have to choose which of the vaccines it can afford and which ones its youngest citizens will have to go without.
Bringing prices down is therefore another crucial priority. One step would be to loosen the stranglehold a handful of pharmaceutical companies have over the vaccine market, allowing greater competition that would drive down costs. GAVI should use its purchasing power to negotiate better prices as well, and, just as importantly, it should give organizations like MSF—organizations that are on the ground, ready to put in the effort to reach as many children as possible—access to vaccines at the prices they negotiate for governments.
As it happens, the pricing process as a whole has too long been shrouded in secrecy. It was only recently that the prices paid for some vaccines were made public, largely as a result of pressure applied by MSF’s Access Campaign and other civil society groups. MSF subsequently published these prices in an April 2012 report called The Right Shot, showing the numbers in stark relief for the first time, and revealing, for instance, that one company, Crucell, charges 40 percent more for the pentavalent vaccine—which covers all five of the WHO-identified diseases mentioned above—than does India’s Serum Institute.
From past work on drug pricing around HIV and other diseases, MSF has learned that transparency in pharmaceutical markets can bringprices down. Two years ago, for instance, the Serum Institute, together with partners like PA TH, a nonprofit committed to finding innovative solutions for health problems afflicting the underprivileged, launched a new meningitis vaccine called MenAfriVac, which protects children from a strain of meningitis (meningitis A) prominent in Africa’s so-called meningitis belt. Because the vaccine was developed to serve people, not profits, it is sold at an extremely reasonable price, just 50 cents per dose. And it lasted longer than the vaccine that was in use. Its widespread roll-out in the region has already led to a significant decrease in the number of meningitis outbreaks.
Having better-adapted vaccines would also help with cost, because there would be less need for cold chain refrigerators and generators and the like. In 2007, Ethiopia learned this lesson the hard way, when it had to more than double its national capacity to refrigerate drugs to accommodate the latest pentavalent vaccine.
These various issues came together in South Sudan’s Yida refugee camp this past year. A huge influx of refugees from Sudan had overwhelmed the services on the ground and created a dismal environment in which disease could easily spread. MSF teams built medical facilities, saw tens of thousands of patients, and provided a wide range of urgently needed services. MSF also identified pneumococcal diseases as one of the main reasons children were dying in the camp and decided to pursue vaccinating children with the pneumococcal vaccine, as well as the pentavalent vaccine.
These vaccines were not yet in South Sudan’s national immunization schedule, though, so MSF had to purchase them itself. But because GAVI does not make its prices directly available to nongovernmental organizations and humanitarian actors such as MSF, it took 11 months of lengthy negotiations and bureaucratic hurdles for MSF to secure access to the vaccine. MSF was finally able to obtain a limited number of doses of the vaccine directly from one of the manufacturers andbegan vaccinating children in the camp in July of this year. This experience points to the fact that a more workable solution is needed to allow humanitarian actors to respond quickly when needs arise.
Supply and the Danger of Interruption
Related to both price and adaptability is the issue of supply. After all, even the best, most affordable products are of limited use if there are not enough of them.
For example: Of the two rotavirus vaccines (the vaccine that protects against diarrhea) that have received WHO approval, one is overwhelmingly preferred by developing countries because it requires fewer doses (two instead of three) and because its packaging is less bulky. It’s a better option for countries with weak health systems. But the shared preference has led to a severe shortage of in the supply of the vaccine. And now roughly one-third of the countries that were planning on introducing it this year may not be able to because there is not enough supply for GAVI purchases.
Millions of children who would not have gotten vaccinated against basic diseases in years past are now protected. There’s never been more money or energy behind the effort to make sure this happened, and GAVI and Gates and others deserve a great deal of credit for the work they’ve done.
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