‘Vaccines key to improving health security’
As the government launched the Measles-Rubella vaccine and rolled out the Pneumococcal Conjugate Vaccine (PCV) in a phased manner while scaling up the Rotavirus vaccine to cover five more states in February this year, Hardnews spoke to Dr Katherine O’Brien, executive director of the International Vaccine Access Center, on the role vaccines can play in improving health outcomes in India
What role can vaccines play in improving overall health security in a developing country like India?
Vaccines are a critical, cost-effective intervention to prevent most causes of childhood illness, long-term consequences of illness, and death. Vaccines create the opportunity for children to survive infancy, childhood and thrive as productive members of the community. Not only do vaccines help prevent diseases that are otherwise a constant threat to families, they also reduce the likelihood of epidemics that can have added consequences, such as social and economic insecurity. Vaccines are especially important in improving equity in health because they can reach those children who are at the highest risk of disease and are least likely to have timely access to curative care when they get sick. This characteristic of vaccines—that they can be delivered through a well-planned, pre-emptive programme—means that there is every opportunity to achieve high coverage if adequate resources and planning are dedicated. Vaccines only work if they are actually delivered to children and don’t just sit on a shelf.
Apart from the introduction of vaccines, what else can be done to improve preventive healthcare?
Vaccines are part of a comprehensive approach to child health, especially for the two leading killers—pneumonia and diarrhoea. Preventive healthcare emphasises protecting children and preventing illness so that precious resources—money, food, time and energy—are directed towards enhancing the health of the child and the family, instead of being spent on treating an illness that could have been avoided. Protecting children from pneumonia and diarrhoea includes assuring exclusive breastfeeding in the first six months of life, adequate nutrition, and Vitamin A supplementation. Preventing disease includes not only vaccination against germs like measles, pneumococcus, rotavirus, pertussis, and Hib, but also handwashing to limit transmission of germs, improved water and sanitation to reduce the likelihood of disease transmission, reducing indoor air pollution which puts infants and children at significantly higher risk of serious respiratory infection, and preventing and treating HIV in both infants and in their mothers and families. Improving access to medical care means assuring that health facilities have the resources (doctors, nurses, medications, diagnostic facilities, etc) they need to treat people when they come for care and people in the community have the means to actually receive that care. This also means an ability to get to the care facility, an ability to pay for the care, an understanding of the signs and symptoms that would necessitate care and the confidence that when they seek care, their child will be managed in a timely and effective way.
What are the factors that have hindered vaccine-related R&D in India? What can be done to remove those obstacles?
Vaccine-related R&D has been progressing more quickly now than at any time in the past. However, there remain barriers that include insufficient financing (i.e. private equity), a regulatory system that has previously managed generic vaccines but is now having to review and approve new technologies and vaccines, vaccine price structures that emphasise low prices and adoption of vaccines in public markets that could be more accelerated and provide more of a pull mechanism. There is a massive global market for vaccines and strong evidence that those markets will remain and grow in the future. This provides a strong impetus for Indian vaccine-related R&D to take the best advantage of those opportunities.
Do you think the introduction of vaccines and improving immunisation coverage can actually reduce public health expenditure over time?
The cost of introducing a new vaccine like PCV, rotavirus, or measles-rubella is far outweighed by the savings to the government, communities and families that result from reduced costs of illness in the short term and increased productivity and economic security over the long term. When the full value of vaccines is considered, vaccines are one of the most effective and cost beneficial interventions available.
From a cost of illness perspective, it is important to recognise that not only are the hospital and other treatment costs for illness episodes expensive, they are not always effective and children die. Our treatments do not work in cases that are very severe, or those that come for treatment very late. Families, especially those already in poverty, can be forced into extreme financial hardship because of the costs of hospitalisation, transportation, and loss of wages for parents. This then sets off a vicious cycle of further impoverishment, poorer nutrition, worse living conditions, less educational opportunities for children, and increases in the short term and long term increased susceptibility among these children to the next disease event. A negative cycle ensues whereby the most vulnerable families are ever more vulnerable, ever poorer and increasingly likely not to survive.
In a study in The Gambia—a setting where healthcare is free of charge to patients—pneumococcal disease nonetheless placed a heavy financial burden on families seeking treatment before arrival at the hospital, paying for transportation costs, drugs, diagnostic tests and even burial in the case of death. Although 50-80 percent of the cost of treating an episode of pneumococcal disease was borne by the health system and paid for by the government, families were still having to cover a cost of up to 10 times their average daily household budget. This burden of cost was enough to throw some families into a downward cycle of extreme poverty from which they were unable to recover. Furthermore, the expenditures from the government to treat episodes of a disease can be very high. The estimated treatment cost for an episode of inpatient pneumonia—$109—is nearly four times the annual per capita expenditure for health in The Gambia.
Societal costs of these diseases are also extremely high, reflecting future productivity losses among children who experience these diseases. In a study of immunisation in the Philippines, children vaccinated against six diseases performed significantly better in verbal reasoning, maths and language tests than those who were unvaccinated. This evidence shows that preventive vaccine investments can provide long-term payoffs from a personal, family and societal perspective.
Modelling shows that investing in vaccines provides a massive return on investment. Vaccinating against 10 diseases in the world’s 94 poorest countries between 2011 and 2020 has been estimated to avert $586 billion in costs of illness (including treatment costs, transportation costs, lost caretaker wages and productivity losses due to death and disability). The 73 Gavi-supported countries account for $544 billion of the treatment costs averted. Compared to the costs of vaccination programmes, these benefits amount to a 16-fold return on investment.
There are some specific examples from India about the value of vaccination from the perspective of public health. An evaluation of the measles vaccine in rural India found that children under five years of age who did not receive the measles vaccine as infants were three-fold more likely to die than were children who had received their vaccine. This was especially true of the children from lower caste households where the risk of dying was almost nine times greater than among children who had been vaccinated. This impact on mortality was not just accrued from a reduction in measles. The vaccine seems to have conferred a non-specific beneficial effect among the immunised children in the population, as well as protection against measles itself. If the findings from this study are true in general, it provides evidence that vaccination among children in the least advantageous economic and social groups may have the most to gain from vaccination.
The plan to roll out the PCV vaccine in four states in a phased manner this year is a step in the right direction. What target should India set for itself for rolling out the vaccine across the country, considering the huge pneumonia burden India bears?
PCV has been rolled out in over 130 countries worldwide. The decision by India to include this vaccine in the package of routine immunisations will have a significant impact on child health in the country, reducing pneumonia and meningitis deaths and illnesses. Pneumonia is the leading infectious cause of death for children in India and pneumococcus is the leading pathogen causing those pneumonia deaths. Starting with high-burden states will ensure that the areas where the vaccine is needed the most will receive it quickly. Eventually, the aim is to provide PCV nationwide as part of the package of routine immunisations supported by the UIP.
Bangladesh has been able to achieve around 80 percent vaccination coverage and has also witnessed a steady rise in the coverage over the past few years. What are some of the lessons that we can learn from their immunisation programme?
Lessons about PCV have been learned from many countries that have rolled out the vaccine in past years, including several countries neighbouring India. PCV is given in a three-dose schedule and ensuring that children receive all the three doses, and receive them in a timely way according to the recommended schedule, is important. If children receive only partial doses or receive them with substantial delay, they remain vulnerable to pneumococcal disease and the benefits accrued to the whole community are delayed. With high levels of coverage, PCV can protect not only those children who are themselves vaccinated but also children too young to be vaccinated and older members of the community. This happens because PCV protects not only against disease in the lungs or the blood or the spinal fluid, but it also protects against carrying the pneumococcal germ in the nose. It is this carriage that, although most often completely asymptomatic and self-resolving, provides the means by which the pneumococcus is passed from person to person. As a result, immunising infants can interrupt the chain of transmission of pneumococcus in the community and those who are otherwise unimmunised also benefit from the vaccine programme in infants.
The only way to accrue the benefit of the vaccine to infants and to their household and community contacts is by ensuring and expanding vaccine coverage. Making a specific and special effort to expand coverage, especially in districts where coverage is low, will help address health equity issues.
Bangladesh has taken a pro-poor strategy and used NGOs to help reach all children. This has helped them achieve gains in not just vaccine-preventable diseases but helped them reach the fourth target of the Millennium Development Goal that aimed at reducing the under-five mortality rate by two-thirds in the period between 1990 and 2015. They have also understood how childhood diseases contribute to a vicious cycle of poor health. Considerable research has been done in Bangladesh, not only to understand the issues, but also to track their progress.
Multiple studies have shown that there are real interactions between the common causes of serious childhood illness, like pneumonia, diarrhoea, measles and malnutrition. The interactions are two-way—poorly nourished children are more likely to fall ill with serious diseases and when struck by one of these illnesses they are more likely to have a serious episode and to die from it. Even when they survive, a child who has suffered from pneumonia or diarrhoea is weaker than before the event. The illness itself contributes to a reduced nutritional state and as a result, the child has an even greater risk of contracting another illness than they did previously. The result is a vicious cycle. So not only is malnutrition a major risk factor for diarrhoea and pneumonia, but diarrhoea and pneumonia are themselves risk factors for poor nutritional status. The consequence of this is that a wholesome approach is needed, which includes preventing these events from happening in the first place, ensuring that children are vaccinated as early as possible with all the doses of recommended vaccines and treating illnesses early and appropriately when they do occur. These interventions, when layered on efforts to nourish and protect young children, can make a major difference not only in the lives of children and their families but in communities and economies.