Lessons learned from the Hib initiative

For 2014’s U.S. Federal Employee of the Year, it’s not enough for health organizations to issue recommendations and expect people or governments to follow them. Change requires direct communication. Dr. Rana Hajjeh, division director of bacterial diseases with the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, was honored earlier this fall for her “significant contribution to the nation in activities related to national security and international affairs,” in an awards ceremony some refer to as the Oscars of U.S. government service. Hajjeh and her team led a global campaign to convince some of the world’s poorest countries to include a vaccine for bacterial meningitis and pneumonia in their vaccination programs. The vaccine counters the root cause, an organism known as haemophilus influenzae type b — or Hib — for which a vaccine has existed since the early 1990s. While Gavi, the Vaccine Alliance offered the vaccine to countries free of charge, approximately sixty countries declined to integrate the vaccine into nationwide programs. Hajjeh and her team began advocating for the treatment in person through education and awareness campaigns. Their efforts will save an estimated 7 million children by 2020, according to the CDC. Devex caught up with Hajjeh, who stressed the importance of local data, coordinating internally and, maybe most importantly: avoiding assumption. Below are a few excerpts from our conversation. What have you learned from this initiative that could be translated to other global health initiatives, and perhaps other campaigns to fight noncommunicable diseases? Communication is important. The scientists often tend to minimize its importance. We tend to focus on getting the studies done, publishing and then we assume everybody should know, right? But what we found is that most of these people never look at any of these papers. Bridging that gap between the science and the decision-maker is really critical. I keep learning this again and again: You can never underestimate the importance of direct communication. We can’t just sit up in our ivory towers — whether its CDC, WHO or Gates or other organizations — and come up with recommendations and assume that everyone is going to follow them. Also, I learned not to make assumptions about anything. You assume sometimes that even the fieldworkers and immunization workers know about the vaccine, and we often found that their knowledge was quite limited, or that they were repeating things that they heard. We tend to underestimate how important local data is. For Hib disease for example, countries didn’t really care if CDC or [WHO] did a study and estimated how much of the disease they had. They want to see data from their own countries and own people. If it looks like there’s a promising intervention, start doing the studies early where you think the highest disease burden is. Engage the country and do the studies early. Many of these countries have a million health priorities, you come with your vaccine or your intervention and they think it’s just another push. You need to figure out how this vaccine fits with their other priorities. With Hib, many countries were under pressure to meet their [Millennium Development Goal 4 on the reduction by two-thirds of infant mortality by 2015] ... and they were really running out of time and options. Many global health experts recognize this need for political will and behavior change to power such initiatives. How did you harness and/or spur these two crucial aspects to adopting the vaccine? We realized early that we needed to do this systematically. Our strategy basically relied on three main components: communications and advocacy — because we knew there was a big gap [and] countries were not fully aware of the benefits — then research, because there were still some questions about the disease and the data burden that countries needed to understand, as well as the impact of the vaccine in certain parts of the world. Also coordination, which required including all the stakeholders to make sure everybody is on the same page. We kind of harnessed the various energies of the stakeholders in the field. This [strategy] is where most of our energy went. And communications was a big thing because we realized there were lots of guidelines and documents about the vaccines that WHO and others put out, and in most instances countries did not even read these things; they did not have access to them. At the same time, for advocacy we found regional disease champions, people who produced the vaccines and dealt with these issues. Sometimes when you come from an international group, those [regional vaccine champions] don’t immediately see that you understand issues. It’s an initiative that is estimated to save the lives of 7 million children by 2020. How do you think this will change the landscape of the 60 countries who adopted the vaccine? These countries started dealing with Gavi for the first time because of Hib. Because of this, they also started dealing with the hepatitis B vaccine. It was their introduction into the whole Gavi process. Many of these countries went on to apply for PCB for pneumococcus, and the rotoravirus vaccine for diarrhea. In the long term, what I think is important in addition to the immediate impact, is the platform we’ve put in place. Countries are smart; they figure out the system. Now many countries are applying for HPV. The structure that this project helped set up is very important long-term. You mentioned the need to be patient when it comes to global health — but what issue can’t wait any longer? What are you tackling now? I’m working on Ebola now, and in the summer I was involved in the Middle East Respiratory Syndrome in Saudi Arabia. Both of these issues are spreading because there is very poor infection control capacity in developing countries. Saudi Arabia isn’t technically a developing country, but it is relatively new when it comes to health and disease infrastructure. This is why I like vaccines, you have one intervention, you do it, you see an impact. Infection control is tedious. It requires training, physical infrastructure, time just to implement. There is a certain infection control mindset and culture. It is very difficult but important work. We have some great vaccines and child mortality initiatives underway. The meningitis vaccine, which has led already to eliminating epidemic meningitis in West Africa, the same area hit now by Ebola. But the more I work in global health, the more need I see to go beyond child survival. So we’re giving these kids vaccines, they’re surviving, but now they need a future. What happens after 2015? It takes the global funding community to make sure their kids are educated, and have other opportunities. Beyond the immunization program, kids still get sick. So I see a need to focus on good health care and opportunities for child development. Want to learn more? Check out the Healthy Means campaign site and tweet us using #HealthyMeans. Healthy Means is an online conversation hosted by Devex in partnership with Concern Worldwide, Gavi, GlaxoSmithKline, International Federation of Pharmaceutical Manufacturers & Associations, International Federation of Red Cross and Red Crescent Societies, Johnson & Johnson and the United Nations Population Fund to showcase new ideas and ways we can work together to expand health care and live better lives.