Imagine how the world would react if with a massive vaccination campaign we could, in one fell swoop, completely eliminate a disease in Africa that regularly threatened as much death, havoc and suffering as the current Ebola outbreak.
Well, it’s already happened.
And a decision today by the World Health Organization is a step toward making sure this killer never returns.
The disease is bacterial meningitis, an infection that inflames the brain and spinal cord. Epidemics of meningitis A used to rage across the center of Africa, from Gambia in the west to Mali, Chad, South Sudan and into Ethiopia. Hundreds of thousands of people could be infected, sometimes with tens of thousands dead and many more permanently disabled, in what came to be known as the “Meningitis Belt.”
Time to just go back to calling it the Sahel. These deadly outbreaks just don’t happen anymore thanks to a vaccine that was developed by a unique partnership, launched more than a decade ago, that may provide a model for how best to develop a vaccine or drug needed only by the poor.
“This was driven by public health not business,” said Kathy Neuzil, head of vaccine access and delivery at Seattle-based PATH. “The fact that we were able to accomplish this over 13 to 14 years in a region with many countries experiencing political instability, coups, disasters and other problems is just remarkable.”
Yeah, so it wasn’t all just one big swoop. The Meningitis Vaccine Project, a collaboration involving many players but led by PATH and the WHO and mostly funded by the Bill & Melinda Gates Foundation, was launched way back in 2001 and took a lot of work, not to mention creative thinking aimed at challenging the common wisdom – of how to make a vaccine. It was a slog at first.
The slog is an important part of this story, and we’ll get to that. But the most dramatic scene is what culminated after the slogging, in 2010 when the new MenAfriVac vaccine was finally, literally, rolled out across the Meningitis Belt and hundreds of millions were immunized.
“Among the 215 million people so far vaccinated, we have not seen a single case of meningitis,” said Neuzil.
“This is such a huge success but what we need to do now is sustain it,” said Marie-Pierre Préziosi, director of the Meningitis Vaccine Project (MVP) based in Geneva. “The transmission of this disease, which is human-to-human, is completely interrupted at this moment. We don’t see the disease now … but it doesn’t end there.”
She said the next step to ensure lasting success against this deadly and, until recently, largely neglected killer in Africa is to move from the big campaign stage to expand the vaccinations to those now mostly at risk.
This has been made possible by WHO’s decision today to approve the use of the vaccine in infants.
“Newborns are still susceptible,” said Neuzil. To fully eliminate this bacterial scourge and create population-wide immunity, she said, newborns need to get the vaccine and the most efficient way to do this is for MenAfriVac to be incorporated into the government’s routine public health immunization program.
This is where the slogging pays off. The next phase of this global health success story moves it from a project pushed by the international community, PATH, WHO and big donors like the Gates Foundation to something African governments, and their health ministries, have to take over – and pay for.
That’s often where such well-intended health initiatives fail. Adding a vaccine or a drug that may only cost a few dollars may not sound like a big deal to an American ear. But most of these countries’ health systems are already stretched pretty thin and paying for one more vaccine or drug gets subjected to some pretty brutal cost-benefit analyses. And if a drug company can’t make money off it, why would it want to invest in making it anyway?
This is the normal state-of-affairs that Bill Gates has criticized as the inherent “market failure” that discourages the biomedical industry from even considering development of drugs or vaccines that only help poor people in poor countries.
What the MVP and the MenAfricVac vaccine appear to have demonstrated is that this failure can be overcome, by a creative merging of commercial interests with a public health mission.
“It’s a pretty unique approach,” said Greg Widmyer, deputy director for vaccine delivery within the development program at the Gates Foundation. What was needed, Widmyer said, was a very inexpensive vaccine that was highly effective, easy to manage (in terms of transportation, storage as well as the actual administration of the vaccine) and somehow financially attractive to the drug industry.
“We had a few bumps in the road,” he said.
The African governments who faced these deadly outbreaks of meningitis were asking for help, but they wanted the vaccine to cost less than a dollar. It had to be made specifically for the strain of meningitis A that afflicted their region. Nobody in Big Pharma or the western biomedical industry had much interest.
But PATH’s Marc LaForce, who founded MVP and led the effort, refused to be swayed by the lack of commercial interest. Given the immense public health need, LaForce continued to look at other options. The Gates Foundation backed him. LaForce, formerly with the U.S. Centers for Disease Control, knew the epidemiology of this disease; he knew scientists at the National Institutes of Health had some interesting experimental vaccines that showed promise against bacterial meningitis. He knocked on doors at the FDA, at various biotech or drug companies and anyone who would listen.
Eventually, LaForce and his gang at PATH convinced India’s Serum Institute that it could benefit from taking on the manufacture of this vaccine, even if they could only charge 50 cents for it. What MenAfriVac represents, in addition to the erasure of the Meningitis Belt, is perhaps one of the first highly successful examples of a (sometimes highly dreaded) public-private partnership in global health.
“We didn’t even want to use that term,” laughed Neuzil. Many at WHO, UNICEF and other potential partners for this project viewed any kind of partnership with private industry as an inherent contradiction and conflict of interest, she said. But what they have shown with this project, Neuzil said, is that the poor can be served by such collaborations if the public health mission takes priority.
“This is an incredibly important proof point in what we hope will become a stream of such projects,” Widmyer said. As a former Peace Corps worker based in Togo (some 25 years ago), he said he can remember when the meningitis epidemics would erupt, creating widespread panic and tragedy. “They would even barricade the roads in Togo to try to combat the spread.”
Amazingly, thanks to this unique vaccine development project, that may never have to happen again.
If the Meningitis Belt does eventually disappear, it won’t be due the typical, often reactive, distribution of a vaccine to quell an outbreak. It will largely be thanks to the proactive slog that first took into account the financial and logistical needs of poor countries, and then found a unique combination of private commercial and public health interests to create a product that met both.
With the WHO approval of the vaccine use in infants, the Meningitis Vaccine Project will close up shop. It even already says “Goodbye!” on its web site.
“Some organizations close because they don’t succeed,” Préziosi said with a laugh. “We are closing because this is such a huge success. Now, we hope these countries will take the next step and make this a lasting success.”