OVERCOMING CHALLENGES TO MEET MSF'S VACCINATION AMBITIONS

Today, 10-month-old Roni will be vaccinated against one of the world’s biggest killers of children his age: pneumonia. He waits patiently, perched on his mother’s hip, as she gives his name and date of birth to the Médecins Sans Frontières (MSF) team working in Yida refugee camp in South Sudan.

While immunisation has always been a major part of MSF operations – with more than two million people protected against measles in 2013 alone, for example – the organisation recently upped its vaccination ambitions. This involves, in part, using the newest vaccines more systematically in MSF operations, including in emergencies, where children are at their most vulnerable. For example, Roni was one of several thousand children vaccinated by MSF in the Yida camp between July and September 2013 with two new vaccines that were not yet available in South Sudan: pentavalent and the pneumococcal conjugate vaccine (PCV). MSF projects are also rolling out innovative strategies, seeking to show in Guinea, for instance, that a new oral cholera vaccine is effective in responding to outbreaks and even works as a useful preventive tool where cholera is endemic.

MSF’s renewed commitment to vaccination as a medical priority centres on the ambition to strengthen routine immunisation, that is to say, the vaccines the World Health Organization (WHO) recommends all children should receive. Four priority countries have been chosen: Central African Republic (CAR), Chad, Democratic Republic of Congo (DRC) and South Sudan. There are many aspects to this work, and one is reducing ‘missed opportunities’ in MSF projects by screening eligible children for their vaccination status during clinic visits. Another is integrating immunisation into other paediatric programmes. MSF projects in Niger, Mali and Chad, for example, are already combining routine vaccination activities with other health measures such as seasonal malaria prevention. A third strategy is pursuing opportunities to find those children over the age of one who haven’t completed the recommended immunisation series and need to ‘catch up’.

However, these new vaccination plans are in danger of being thwarted by the issue of price, and by the very nature of the vaccine product itself. MSF, through specific campaigning and advocacy, needs to address these issues, while also focusing on innovative operational activities and research.

When price curtails ambitions

The GAVI Alliance – the foundation that procures vaccines on behalf of many developing countries – has been instrumental in negotiating substantially lower vaccine prices for the world’s poorest countries. This has helped to improve availability of the newest vaccines in countries hardest hit by diseases like pneumonia.

These lower prices are, however, only available through specific purchasing channels, and MSF has not been able to systematically access the ‘GAVI price’. Nor does GAVI have policy provisions that cater to emergency situations, as it is a development organisation focusing on the WHO’s Expanded Programme on Immunization (EPI). WHO released new guidelines last year which recommend vaccinating in humanitarian emergencies, yet accessing vaccines at an affordable price and in a timely manner remains a hurdle.

With the escalation of the humanitarian crisis in South Sudan, MSF sought to vaccinate vulnerable children in Yida camp against pneumonia. It took 11 months to organise the campaign because of problems accessing the vaccines, an untenable timeline for an emergency response. 

So why did it take so long? The reasons were complicated price negotiations with pharmaceutical companies GSK and Pfizer, and with the GAVI Alliance, and lengthy procurement processes. With the growing refugee crisis and MSF’s frustration at the inability to purchase PCV at the GAVI price, the MSF Access Campaign went public in April 2013 with its Dear GAVI social media campaign, urging the alliance to open up its discounted prices to MSF and other humanitarian organisations. Ultimately, MSF was able to access PCV at a price of US$7 per dose – still double the lowest global price paid by GAVI.

The Dear GAVI campaign brought mixed results, and while GAVI has publicly committed to making its prices available to humanitarian organisations if they use its procurement channels, MSF will still push to purchase vaccines at the lowest global price directly from pharmaceutical companies. These companies – who are ultimately responsible for pricing decisions – refuse to sell their vaccines to MSF at the cheapest possible price, so the Access Campaign continues to advocate for greater affordability and access.

Vaccines on ice

More than 22 million children each year go without the basic package of vaccines recommended by WHO, largely because delivering these products to remote areas is remarkably challenging. Vaccines are usually developed with wealthy-country conditions in mind: reliable and constant electricity to keep vaccines refrigerated; qualified health workers able to deliver injections; the means to safely dispose of syringes; and the relative ease for most caregivers to reach a vaccination point, meaning that the multiple visits needed to complete a complex immunisation schedule – a minimum of five – are feasible.

Little of this applies to many developing countries where the most vulnerable children live. MSF field logisticians say that the need for vaccines to be kept at the right temperatures, in a constant ‘cold chain’, is one of the biggest barriers to expanding the reach of vaccinations. For an MSF measles vaccination campaign in Chad, for example, 21,500 ice packs were required, and this involved 18 freezers and three freezer rooms. Then there is the added complexity that vaccines need to be kept cold, but not too cold – vaccines can accidentally freeze when they’re stored against ice packs while on their way to vaccination points.

MSF is therefore campaigning for easier-to-use products, particularly vaccines that are more tolerant of heat for the very last stages of their journey from a health centre to the patient. This is being achieved in part through operational and clinical research: in 2013, MSF and its research arm Epicentre carried out a study to determine the stability and continued efficacy of a tetanus toxoid vaccine that was kept in a ‘controlled temperature chain’ at ambient temperatures of up to 40°C for up to 30 days. The results so far are promising, and once the data has been released it should be possible to use it to push for the vaccine to be re-labelled, allowing it to be kept for a certain period of time outside the cold chain. Pushing pharmaceutical companies to re-label their vaccines for use outside the cold chain for even several days would be helpful for campaign and outreach programme vaccines.

This, however, is just the beginning as ultimately we need pharmaceutical companies to develop future products that prioritise thermostability, so that vaccines can be left out of the cold chain for at least a month.

The cost of fully vaccinating a child has increased by 2,700 per cent since 2001, and humanitarian organisations and many countries are therefore finding it increasingly difficult to afford these essential health tools, and then there are the added problems of vaccines that require cold chain, and the complex logistics of a vaccination programme in remote areas. What MSF is witnessing in the field – children dying from vaccine-preventable diseases – is spurring us on to improve our programmes and to speak out about what changes the vaccine community needs to make. If we want to reach the 22 million children that go unvaccinated every year, GAVI, pharmaceutical companies and donors must work together. We need products that are better suited to the places where we work and to those who require them most, and we need access to them at the lowest prices. 

 

WE NEED EASIER-TO-USE VACCINES

Five Vaccination Visits are Required Before a Baby’s First Birthday. This can be Difficult for Caregivers in Developing Countries

Schedule is WHO-recommended routine immunisations for children
 

WE NEED MORE AFFORDABLE VACCINES

Two New Vaccines Account For 74% Caregivers in of the Cost to Vaccinate a Child

Total cost of vaccine package in a developing country:

$38.75
 
UNICEF Vaccine Price Data: http://uni.cf/mti97E All Measurements in US Dollars Price per vaccine is based upon the WHO-recommended number of doses Pentavalent vaccine protects against five diseases: Diphtheria, Tetanus, Pertussis, Hep B, Hib