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GAVI’s Special Representative to GAVI Eligible Countries
Photo credit: GAVI/2012/Olivier Asselin
I accompanied GAVI CEO, Dr Seth Berkley, on a joint country visit with Bill Gates to Ghana two weeks ago. This was Mr Gates' first visit to the Ghana Health Service.
We spent our first morning in the field, visiting the Community-based Health Planning & Services initiative’s compound, which is part of the strategy for changing primary health care from a focus on clinical care at district and sub-district levels to a new focus on high quality services at community and doorstep locations.
The Community Health Officers were working at an outreach clinic, under a shady tree providing some cover from the hot sun. They showed us their child registers and 'Well Baby Clinic' cards with records of vaccinations, weight and other relevant child health records. This particular district is also using mobile phone technology to register pregnant women. Regular messages, including vaccination appointments are sent in the local language to mothers.
The Community Health Officers use this mobile technology to generate a list of expected clients and defaulters for follow up. They also use paper systems of child health cards and registers as well as logbooks in clinics to track a child’s progress with vaccinations.
Mr Gates witnessed real progress in using the paper system and the culture of data that it supports. For example, the district holds regular monthly meetings to validate data before it is shared with higher levels.
At the end of the day, the health workers were happy with Mr Gates summary of the visit: "The system is not perfect but it works."
I was reminded of his words in subsequent conversations I had with family and friends the following week. My cousin, a dermatologist, praised the Community Health Officers for the way they keep and use immunisation data. Monthly inter-district review meetings were opportunities to share best practices and validate data on reproductive and child health including immunisation. She wished clinical services were as organised as the preventive services organised by the Community Health Officers.
At a subsequent dinner organised by some retired public health colleagues, one of them described how medical students he examined could not remember the last time they saw a case of clinical measles. He spoke eloquently about the dedication of Community Health Officers at peripheral levels of the health care system in bringing services including immunisation to communities. Countries unhampered by the scourge of vaccine preventable diseases can rise to their full developmental potential, he said.
More should be done by the Ghana Health Service and development organisations to publicise how we are contributing to national prosperity. Strong primary health care systems are the bedrock of successful immunisation programmes, which ultimately contributes to saving lives.
I was at Yar Akwa health post in Kano, Northern Nigeria last Friday. We had 2 Community Health Extension Workers (CHEW) preparing to vaccinate about 15 children who have shown up with their mothers for the vaccination session. I started a discussion with the mothers on reasons for vaccinating their children.
They believe immunisation is critical for the well-being of their children. Measles was mentioned as the most feared vaccine preventable disease. It causes blindness, deafness and pneumonia among others. I was flooded with memories from the paediatric wards in Kumasi, Ghana where I did my house job as a newly qualified doctor; 3 -4 children squeezed into a cot with the complications mentioned above from a measles outbreak. This is why I got into public health. Ghana has improved routine measles coverage since then with no recorded measles death since 2003 (measles vaccine coverage was 91% in 2011).
I first heard about GAVI in November 1999 while on a short course on Epidemiology at the CDC in Atlanta. I had gone to the offices of the Hepatitis branch to solicit support for Hepatitis B vaccine introduction in Ghana’s immunisation programme. ‘Don’t you worry’, a staff member told me. An organisation called GAVI is going to be set up soon. They will solve all your problems. They will provide support for new vaccine introduction in developing countries. I heaved a sigh of relief and waited with bated breath for the creation of the new public-private partnership.
I was not disappointed. Ghana was one of the first countries to apply for GAVI support in June 2000. We introduced the pentavalent vaccine (five-in-one shot against diphtheria, tetanus, pertussis, hepatitis B and Hib) in December 2002. Other new vaccines followed.
By the end of 2011, GAVI had contributed to the immunisation of an additional 325 million children, who might not otherwise have had access to vaccines, and averted more than five-and-a-half million future deaths.
The GAVI Alliance Board in June 2012 approved support for measles supplementary immunization activities for Nigeria to sustainably prevent measles deaths.
I was in Ghana last week, following up on preparations to introduce two new vaccines against diarrhoea and pneumonia. I had visited Akwapim North district, some 50km from the hustle and bustle of Accra. The view from the hills was serene and the air felt fresh after a light rain. Dr Joseph Opare, the District Director of Health Services (DDHS) and Rachel, the District Disease Control Officer took me round the district, visiting health facilities and outreach centres.
As we chatted between visits to villages I probed deeper to get a better understanding of why immunisation coverage is increasing in his district, (DTP3 >90%). I had attended the 2011 performance review meeting of senior health managers in Accra the previous day. The national DTP3 coverage is stagnating around 88% and there was general agreement that it was mainly due to late release of funds for service delivery.
He described how his team strategized to increase coverage:
What struck me was how the DDHS focused on his area of influence to improve service delivery and coverage without pointing fingers at others. He had other issues to deal with as we went round: suspected measles outbreak (5 cases), industrial action by some health workers, a cholera case, plus the fact that I had taken him away from other duties he had to perform that morning…
Much discussion has gone into the importance of country ownership in ensuring sustainability of programmes. District ownership is critical to increasing and maintaining high coverage. Districts like Akwapim North need to be encouraged to continue innovating to save lives.
Mercy AhunDr Mercy Ahun, GAVI’s Special Representative to GAVI Eligible Countries
I landed at 4.30 am in Trivandrum, Kerala State, and I could hardly contain my excitement. We have been working with India’s Ministry of Health and Family Welfare for the past two years after they were approved by the GAVI Board for pentavalent vaccine introduction; and finally it’s happening, with Kerala and Tamil Nadu, two states with high immunisation coverage, taking the lead.
At the Women and Children’s Hospital, Thycaud, Trivandrum, the media were out in force to report on the first launch of pentavalent vaccine in the public sector in India.
Speaking in Malayalam, The Minister of State of Health told the crowd of 150 why the state was introducing pentavalent vaccine. He said they had put together a group of experts and determined they could further reduce by half their relatively low infant mortality of 16 per 1000 live births by 2015.
I said a few words on behalf of GAVI, expressing our support for Kerala’s achievement. The first baby was vaccinated and by the end of the first day about 6,000 infants had been vaccinated. The target is 530,000 infants for the year.
The pentavalent vaccine has been used in private clinics for a decade already. Introduction in the public sector is a matter of equity and fairness for all. Babies from low-income families also have rights!
The Director of Immunisation of an adjacent district I visited asked “Where do you come from?”, “Ghana,” I responded. “Have you introduced Penta in your country?”, “Yes, we introduced in 2002”. “You mean you introduced almost 10 years ago!?”. This was followed by a reflective silence.
On my traffic jammed way back to Trivandrum, I reflected about my experiences of seeing countries introduce new vaccines -- the excitement, the involvement of politicians and other key stakeholders and how the profile of the immunisation programme has increased after the doldrums of the post-Universal Childhood Immunisation years. We still have a long way to go in improving the programme.
My next stop is Tamil Nadu.
After arriving in Chennai, I called Dr Jameela , the state director of health services in Kerala, to thank her for the warm reception. She told me about the upsetting news of an adverse event following the previous day’s immunisation. Together with the state government, our partners from WHO and UNICEF immediately started investigating.
The venue for the launch of pentavalent vaccine in Tamil Nadu is the Alamelrangapuram Primary Health Care centre in Vellore.
We met a bigger crowd; twice the size of Trivandrum, the dais was decorated with flowers and had big banners to mark the occasion. The state was organising a double launch for pentavalent and a campaign against smoking. I met the PHC director and her staff who showed me round the centre. The mothers with their babies to be vaccinated were seated and wore their numbered badges. It was clear which baby was to be vaccinated first. A very orderly arrangement!
The press with their cameras were also there in numbers. I was introduced to WHO and UNICEF staff and also met Dr Jacob John, the former chair of the National Technical Advisory Group on Immunisation (NTAGI). He was clearly excited about the introduction of pentavalent vaccine into the public health system after it has been used in private clinics for some eight years.
The State Minister of Health arrived at 11am with his retinue. Among the speakers at the ceremony were the Minister for Development, Mayor, Local Assembly representative. The State Minister of Health who is a doctor gave the first shot. I jostled with the cameramen to get a good view and a photograph.
Finally, an hour and a half later, the launch had gone smoothly, all the babies have been vaccinated.
Mission accomplished. Pentavalent vaccine is finally launched in the public sector in India.
At a point in time it looked like it wasn’t going to happen this year, but the GAVI Alliance has “country-driven” as one of our core principles and India determined when it was ready to introduce and informed us. All I did was rely on my colleagues in India to make it happen. And they did. Additional states have indicated their interest to introduce penta in the near future.
Thanks to all who made this possible.
Mercy AhunManaging Director, Programme Delivery, GAVI Alliance
Immunising children against polio in remote Ghanaian villages a decade or so ago, I came across a case of pneumonia that has haunted me to this day.
After riding pillion on a motorbike for hours through cornfields, we arrived in a small hamlet of three mud huts. The men were eating lunch and the women were on the periphery, attending to their ‘household chores’. We extended traditional greetings and asked to see any children under the age of five.
From the corner of my eye, I noticed a young child, about 18 months old, lying on a mat and I took a closer look. She was an ill looking toddler with fast and shallow breaths. I touched her. She was feverish. I did not need my stethoscope to diagnose pneumonia.
We did not have antibiotics with us, the only effective treatment. So I told the father he must take her to the nearest clinic.
You must not be serious, his body language said. He could only get to the nearest clinic, more than 20 miles away by borrowing a neighbour’s tractor. But he would still have to find fuel and his daughter would be dead on arrival.
He turned away, pain in his eyes. This was clearly not the first time he had faced a similar situation. I stood there riveted. How could I leave this child to die?
A couple of decades later, I still wonder what happened to this child. My mind refuses to accept the obvious. But this is my motivation for working at the GAVI Alliance.
GAVI now supports developing countries to introduce the pneumococcal vaccine that protects against pneumonia, the biggest killer of children. With sufficient donor support, this vaccine could save 7 million lives by 2030.
And then maybe, I’ll never see such a tragic scene again.
This blog post is also featured on the Bill & Melinda Gates Foundation website.
Growing up in a Ghanaian coastal village, the dry and dusty trade winds that blew in from the Sahara were associated with Advent, Christmas, and happiness.
But as I moved inland with my work, they also became linked with meningococcal meningitis A, Ghana’s most common form of meningitis, which brought major epidemics every 8 to 12 years.
Meningitis A strikes children and young adults suddenly, causing severe headaches, fever, and a stiff neck. Patients can die within 48 hours.
I still remember the hospital wards, where I used to work. Meningitis patients were usually on the floor because their seizures made them fall off the bed. As a medical student, I often had to bend the rigid patients into a foetal position so that I could extract the cloudy fluid from their spinal cord and confirm the suspected diagnosis. Year after year, we gave intravenous antibiotics every four hours and prayed the patient would survive without major complications.
MenAfriVac, a new vaccine against Meningococcal Meningitis seroptype Nm A, is expected to prevent meningitis epidemics in Africa's "meningitis belt" of 25 countries that stretch from Senegal in the west to Ethiopia in the east.
In 1989, I became the district medical officer responsible for preventive health of a city of one million people. On one memorable occasion, with an epidemic threatening, a terrified crowd of people nearly broke down the vaccine cold store door in an attempt to get the vaccine. The fear on their faces was palpable.
Then, in 1997, the biggest ever meningitis A epidemic struck, not just in the four northern regions as usual - but throughout the country - hitting about 20,000 people.
And just a few years later, in 2001, a close relative of mine - a healthy 20 year old - began complaining of a headache. He later collapsed and was given intravenous antibiotics. Within 48 hours he was dead.
His death devastated my family, with rumours amok about the role of evil spirits. A decade later, my extended African family is still coming to terms with the loss.
I’m proud to say the GAVI Alliance has just committed another US$100 million to support the roll-out of a new conjugate vaccine, MenAfriVac™, to rid the region of these meningitis A epidemics. If our pledging conference is successful on 13 June, GAVI will be able to roll this vaccine out to all African countries at risk.
This Christmas, I am taking my children back to Ghana. The new MenAfriVac™ vaccine gives us the opportunity to celebrate without fear of this ancient scourge. It provides us hope for the future.
© GAVI Alliance 2013
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