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UGANDA: The Value of Immunisation Programmes

Joshua Kyalimpa and Terna Gyuse

KAMPALA, Jun 14 2011 (IPS) - GAVI, the Global Alliance for Vaccinations and Immunisation, secured pledges of 4.3 billion dollars from donors in London on Jun. 13 with the aim of securing funding to ensure life-saving vaccinations for every child on the planet.

The Malaria Vaccine

"The World Health Organzation has indicated that, if results confirm safety and efficacy, a policy recommendation is possible as early as 2015, paving the way for countries to implement," says Dr Christian Loucq, director of the PATH Malaria Vaccine Initiative.

The RTS,S vaccine, the most advanced candidate vaccine against human malaria) was developed over the past decade at a cost of around 300 million dollars by pharmaceutical giant GlaxoSmithKline, with an additional 200 million dollars in support coming from the Malaria Vaccine Initiative. MVI this month announced the first clinical trials of a second- generation vaccine.

This alternative approach will combine RTS,S with another vaccine being developed by Dutch pharmaceutical company Crucell. Preclinical trials suggest that a dose of Crucell’s vaccine, followed by two booster shots of RTS,S stimulates a stronger immune response than either vaccine administered alone. Where RTS,S offers 50 percent protection, the aim is to produce a vaccine offering 80 percent protection against clinical malaria by 2025.

The alliance, which includes international relief agencies, charities, drug companies and national governments, was seeking 3.7 billion dollars in pledges to increase access to new and underused vaccines around the world.

As many as two million children – overwhelmingly in low-income countries – die each year from diseases which could be prevented by vaccinations such as pneumonia and diarrhoea. GAVI’s programmes have already immunised well over a quarter million children in the past 10 years, and if the pledges from the London conference are honoured, the money will allow the alliance to reach a further 243 million by 2015.

Entering an age of immunisation

Thanks in large part to GAVI, the past decade has seen renewed attention to developing vaccines against diseases affecting the world’s poorest, including meningitis, pneumococcal disease and malaria.

Among the organisations whose investments have supported a breakthrough in prevention of one of the world’s most dangerous diseases is the Malaria Vaccine Initiative (MVI), a global programme of the independent non-governmental organisation PATH.

Malaria vaccines are a long-overdue means to prevent infection and work towards eradication of the disease. The eradication of malaria in the developed world has been cited as one reason developing a vaccine previously received little attention from pharmaceutical companies or government research facilities.

The debut of a first vaccine against malaria, for example, could now be less than five years away – final testing is under way in seven countries.

Yet developing an effective vaccine is only part of the challenge – effectively integrating it into public health will require careful planning and execution.

The recent history of Africa’s immunisation programmes – from the re-emergence of polio in West and Central Africa, to the persistence of meningitis and infant pneumonia – is littered with promising solutions that have failed to have the expected impact. Against a background of poverty and conflict, vaccination campaigns have been hampered by weak infrastructure, insufficient staff or funding, and even popular resistance to vaccinations.

Across the continent, there is new attention to the practical requirements of effective immunisation campaigns. Dr Seraphine Adibaku, head of Uganda’s malaria control programme, says his country has already started raising popular awareness of the coming availability of a malaria vaccine, with the most recent meeting of officials from the ministry of health and developers of the vaccine and other stake holders held in May.

“We are conscious not to cause excitement because it can lead to undesirable consequences but we have to tell the people that a vaccine could be here sooner than later,” says Adibaku.

Uganda is banking on using infrastructure like ware houses and refrigerators from the Uganda National Expanded Program on Immunisation, which is already in place and has been used on previous immunisation programmes, to roll out the malaria vaccine. Adibaku says training will be given to vaccinators on handling the new vaccine with funding from GAVI, all of which shall be in line with the national vaccination policy.

Adibaku has questions about the vaccine: “We do not know yet for how long the vaccine will offer protection. Do you get protection for six months, one year, or for the rest of your life? These are some on the questions not answered yet.”

He says for a vaccine to be effective, it should offer a high level of protection – between 80 and 90 percent – provide long-lasting resistance, and be affordable.

Uganda’s Malaria Programme

Uganda's malaria control programme has thus far relied on mosquito and parasite control using insecticide treated nets, indoor residual spraying, limited larval control and provision of effective medicines such as artemisinin combination therapy to treat those affected. Yet health authorities estimate that 360 people die of malaria every day in Uganda.

Even before the RTS,S vaccine countdown reaches completion, other advances have been implemented. In the Najembe Health Centre in Buikwe district in central Uganda, Namsoke Prossy watches over her four-year-old son. He is lying on a bed in the corner of one of the wards, a drip attached to the window frame providing an urgent dose of quinine.

He is on this venerable medication - rather than an artemisinin combination therapy such as Coartem - says Aisha Kayuki, because a test showed he has a "complicated" case of malaria. Kayuki, whose primary responsibility here is as a midwife, shows IPS the SD Bio Line Malaria test kit they have just begun using. Where the staff at many rural health centres previously had to judge malaria infection from symptoms, or have a lab technician look for malaria parasites under the microscope, the new test allows accurate testing for malaria in just 15 minutes.

It's far cheaper than paying for a lab technician - and the simple kit can be used by anyone at the centre, meaning an accurate diagnosis can be made around the clock, and the right medication prescribed.

On this last point, Adibaku says a vaccine would be a potent new tool, but worries that high costs could leave poor countries like Uganda unable to make it available.

New resolve to get it right

The London conference on funding for vaccines is an important signal that the value of immunisation programmes is understood by both donors and governments seeking assistance.

“When GAVI got started, it was something that had never been tried before,” says Dr Helen Saxenian, from the Results for Development Institute.

“The idea was that prices would fall (once large-scale demand for vaccines was created) and so some countries would be able to afford them without assistance. GAVI quickly realised prices were not – and are not – falling fast enough, and realised the alliance would need to be involved with subsidising vaccines for a longer period of time.”

The reasons vaccine prices have not fallen include the cost and complexity of producing newer vaccines, as well as limited competition between a very small number of producers; but Saxenian points out that there have been some successes, notably for the rotavirus and pentavalent vaccines.

In 2008, GAVI introduced a requirement for recipients of assistance to co-finance the procurement of vaccines. The Results for Development Institute recently evaluated GAVI’s policy on co-payment, to assess the ability of countries receiving assistance to cover their share of the costs.

“The finding,” says Saxenian, “is that low-income countries will not be able to pay the full cost of vaccines any time soon. However co-payments (from national budgets) at 20 cents per dose would be affordable for almost all countries.”

Shared responsibility maximising impact

She argues that the co-financing requirement has been a valuable learning process for all involved. It has strengthened forward planning by national health ministries, communication between health ministries and finance ministers who must make appropriate and timely allocations from national budgets, and between various countries and the UNICEF Supply Division, through which all of Africa’s GAVI aid recipients purchase vaccines to meet their obligations.

Aid recipients have said that they prefer to contribute part of the cost of paying for vaccines, says Saxenian. “Immunisation managers would like to see national budgets for vaccinations grow. It’s a key priority for healthcare, and since one can’t assume that donor assistance will last forever, they would like to see national budgets for it grow,” she told IPS over the phone from the United States.

“A basic way of thinking about this is that if something is completely free, there’s not as much of a sense of ownership as when you’re paying for even part of it. When it’s free, then countries may think, I’ll take it, whether they’re ready or not to adopt it.”

Adibaku says that when one considers the cost of Malaria to the national economy, Uganda should be able to contribute to the vaccination programme but if it is within the range of what they have been spending on the disease

Alongside the pledges from public and private donors to support immunisation, developing countries also renewed their commitments to co-financing in London, with GAVI estimating their contribution will reach 100 million dollars a year by 2015.

Developing countries could be required to make substantial contributions towards a malaria vaccine but this could be a worthwhile investment considering the amount of money the economy looses because of their illness.

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