Opinion: 10 signs we’re winning the fight against pneumococcal disease

During World Immunization Week, I’ve been reflecting on a major milestone: It’s been 10 years since the first low-income country, Rwanda, introduced pneumococcal conjugate vaccine into its infant immunization schedule. Around that time in 2010, more than 440,000 children under the age of 5 died each year from pneumococcal disease in the form of pneumonia, meningitis, and other serious infections, according to an upcoming report from Johns Hopkins University. 

When an effective vaccine for children was developed, only a handful of rich countries that could afford the $71-per-dose price tag were able to quickly introduce it into their vaccine program. The children who needed the vaccine most — those at the highest risk of hospitalization and death — had no access. This was typical; historically, 15 to 20 years have passed between licensure of new vaccines and the introduction of those vaccines in low- and middle-income countries.

If that trend had stood with the pneumococcal conjugate vaccines, that would mean that even today, children in low-income countries including Rwanda would be dying of vaccine-preventable pneumococcal disease, while children in high-income countries were protected.

But the introduction and uptake of PCV in low-income countries, supported by Gavi, the Vaccine Alliance, represented the fastest global rollout of any new vaccine into low-income countries. While pneumonia remains the leading cause of death in children under 5, mortality is dropping every year as more children get access to PCV.

We’ve achieved global access on a scale no one predicted. Here’s 10 signs of that progress:

1. Over 140 countries have introduced PCV, including 60 low-income countries. More than 70 million infants are vaccinated with PCV. But more progress is needed: While fewer than 15 Gavi-eligible countries have yet to introduce the vaccine, there are about 30 million infants in these countries missing out each year. 

2. India, which suffered the world’s highest toll of pneumococcal disease, began a phased introduction in 2017. India had been losing one child every eight minutes to pneumococcal disease. Now, the South Asian nation is now tackling this problem in its states with the highest levels of child mortality. A multi-tiered surveillance network will monitor the impact of the vaccine.

3. Policymakers are better informed on the economic burden of pneumonia. While vaccines are known to be one of the most cost-effective public health interventions, policymakers are now more aware of how much childhood illnesses such as pneumonia cost families and health systems. When children are hospitalized, families often use savings, take out loans, or sell property to pay for treatment. Parents’ time away from work can have serious financial repercussions, and out-of-pocket spending to treat child pneumonia can be catastrophic and may push families into poverty.

4. An innovative financing mechanism will provide nearly 1.5 billion doses of PCV to infants in Gavi countries by 2024. The Advance Market Commitment — developed by Gavi in collaboration with the World Bank and UNICEF’s Supply Division, and funded by Italy, the United Kingdom, Canada, Russia, Norway, and the Bill and Melinda Gates Foundation — has enabled low-income countries to access PCV at a fraction of the cost that high-income countries pay. This report has the latest on impact.

5. The price of vaccines continues to fall. The PCV price for developing countries has dropped from $7 per dose to about $3 per dose. The price drop is expected to lead to savings of $4.1 million to Gavi and developing country governments in 2019 alone.

6. Newest formulations of PCV are better suited for low-resource settings. PCV is now available as a four-dose vial, taking up much less refrigeration space than single-dose vials.  

7. Middle-income countries are funding their own PCV programs. With the growing understanding of the economic value of vaccines, developing countries with growing national incomes are increasingly financing the cost of PCV through their governments. In 2016, Mongolia, which had previously received support from Gavi for new vaccine introductions, introduced PCV at the Advanced Market Commitment “tail price” of about $3. Data collected by countries show how quickly the vaccine starts working. Just one year after the PCV program began in Mongolia, the vaccine-type strains were beginning to disappear from circulation.

8. Evidence of strong impact mounts across Africa. PCV’s effectiveness in high-income counties has long since been demonstrated, and now we can see the value in low-income countries. The incidence of serious pneumococcal disease in Kenya caused by vaccine-type strains dropped by 92 percent among children under 5 years of age, and PCV reduced all pneumonia hospitalizations by more than one-quarter. 

9. Levels of disease have dropped even for people who weren’t vaccinated. The incidence of disease among unvaccinated older age groups also dropped sharply in Kenya, suggesting that the vaccine produced an added “indirect protection” benefit. This occurs because children who have been vaccinated no longer transmit the disease in their community.

10. PCV will prevent over half a million child deaths in low-income countries by 2020. Fifteen years ago, hardly anyone thought we could do this. Ten years ago, we knew the future would be changed for children in low-income countries. I am proud to have worked with a group of doggedly determined, absurdly optimistic individuals who made it happen. And here’s hoping we keep committed to this path to bring PCV to the tens of millions of children still unvaccinated in the poorest nations in the world.