Got vaccines? Got life!

Disease outbreaks

Got vaccines? Got life!

Helping countries to prevent and respond to disease outbreaks is becoming an increasingly vital part of Gavi’s work. Recognising the need for integrated solutions to the prevention of disease outbreaks, the Alliance is working with countries to strengthen comprehensive immunisation services; including routine immunisation, preventive campaigns and the availability of vaccine stockpiles.


Overview

The global health landscape is changing rapidly, increasing the risk of epidemics. While there have been significant improvements in the international community’s capacity to prevent, detect and respond to outbreaks over the last few decades, a number of factors – including climate change, population growth, conflict and poverty – are posing a real threat to global health security. New pathogens almost tripled from 1940 to 2000 with the number of drug-resistant pathogens increasing five-fold (see Figure 1).[1]

High population density and the sharp increase in the number of people living in urban areas further raise the risk of large-scale disease outbreaks. If a transmissible disease like yellow fever starts spreading in a densely-populated slum, it can spread quickly, causing suffering and loss of life as well as interrupting trade, travel and economic activity. These risks are particularly exacerbated in countries with weak primary healthcare systems and low detection and response capacity.


Climate change is increasing the frequency, range and spread of vector- and water-borne diseases. Among other effects, this is changing the burden of mosquito-borne diseases such as malaria and yellow fever. WHO estimates that by 2030 rising temperatures will lead to 60,000 more deaths from malaria every year.

In addition to the heavy price that countries pay both in human lives and suffering, epidemics also carry a heavy financial cost. According to the World Bank, the Ebola outbreak which devastated West Africa in 2014–2016 caused cumulative GDP losses totalling US$ 2.8 billion in 2015. The outbreak undermined private sector growth, agricultural production and cross-border trade, reducing GDP per capita by an average of US$ 125 in the three countries.

Preventing epidemics requires an integrated and multi-track approach. The Alliance is working together to mitigate the risk of outbreaks of vaccine-preventable diseases by supporting early detection and response. This covers several fronts, from strengthening routine immunisation programmes and supporting quality campaigns, to investing in strengthened disease surveillance and funding vaccine stockpiles, with the goal of helping to bolster primary healthcare systems – the first line of defence against outbreaks.

Gavi also uses its market shaping expertise to create the right market conditions to ensure the right vaccines are available to prevent and control outbreaks. Learn how Gavi’s market shaping efforts have transformed the markets for oral cholera and yellow fever vaccines.


MEASURING COUNTRY PREPAREDNESS FOR DISEASE OUTBREAKS: READY, STEADY, ASSESS

The ReadyScore, based on WHO’s Joint External Evaluation (JEE) data, identifies whether a country is prepared to prevent, detect and respond to infectious disease threats. It represents the average score across 19 preparedness areas; including immunisation, national laboratory system, real-time surveillance, and emergency response operations. . Each is based on assessments by national and international experts, ranking epidemic preparedness on a scale from 0 to 100, with the former signifying a complete lack of preparedness. A score higher than 80 indicates that a country is “well prepared” for an epidemic.

As shown in Figure 2, 22 low-income countries, mostly located in Africa, scored an average of 40, indicating their lack of preparedness for coping with disease outbreaks. All countries examined achieved an average of less than 80, underlining the need for significant improvements.


OUTBREAK DETECTION, PREVENTION AND RESPONSE: GAVI’S FRONTLINE ROLE

With US$ 1.1 billion of investments in disease outbreak prevention, detection and response approved since 2016, Gavi is a key contributor to global health security.

Prevention

Outbreaks of vaccine-preventable diseases are often a sign of weaknesses in national immunisation programmes. While Gavi recognises that campaigns are essential to vaccinate those who are missing out on routine immunisation, the Alliance puts strong emphasis on the importance of routine immunisation as a long-term solution to prevent disease outbreaks. Gavi funds routine vaccination programmes as well as vaccination campaigns against several outbreak-prone diseases.

Detection

Effective and affordable, quick and definitive diagnostic capacity is often missing in the countries where it is most needed, creating serious global health security blind spots. During the 2014 Ebola epidemic in West Africa, the first cases were initially misdiagnosed as cholera, and then later as Lassa fever on the basis of clinical symptoms. It took nearly three months before blood samples sent to Europe finally identified the disease as Ebola, during which time it was allowed to spread.

In this reporting period (2016–2018), Gavi invested more than US$ 72 million in disease surveillance, a key component in detecting outbreaks. This support has helped equip health facilities with surveillance software, cover operational costs of routine surveillance and finance appropriate training for staff.

Emergency response

In addition to supporting routine immunisation and campaigns as well as strengthening disease surveillance, Gavi is the sole funder of emergency stockpiles of yellow fever, oral cholera and meningitis vaccines. Since 2012, the Alliance has also contributed US$10 million per year to the Measles & Rubella Initiative towards measles outbreak response in Gavi-supported countries. To date, approximately 50 million children have been vaccinated thanks to this funding.

The Alliance has also committed to financing an Ebola vaccine stockpile once the vaccine has been licensed, prequalified and recommended by WHO.

To ensure a rapid response to cholera, meningococcal and yellow fever outbreaks, Gavi-supported countries have access to stockpile vaccines free of charge. They can also access funding to cover the operational costs of campaigns. Non-Gavi-supported countries facing emergency outbreaks can draw on stockpiles immediately, but they are expected to reimburse the cost at a later date. Since 2017, Gavi has served as an observer to the International Coordinating Group (ICG) on Vaccine Provision. The Alliance also participates in Measles Rubella Initiative outbreak response decisions.


RESPONDING TO EBOLA OUTBREAKS: FOCUS ON THE DEMOCRATIC REPUBLIC OF THE CONGO

The two outbreaks of Ebola in the Democratic Republic of the Congo (DRC) in 2018 underline the importance of having an emergency stockpile of vaccines ready to deploy, as well as strong surveillance systems capable of detecting cases at an early stage. Timely and reliable diagnostic testing is also proving essential in detecting and treating cases.

Timeline

January 2016
Gavi announces an Advance Purchase Commitment with Merck, providing US$ 5 million towards the procurement of an Ebola vaccine once licensed, prequalified and recommended by WHO.

As part of the agreement, Merck agrees to create and store a stockpile of 300,000 doses of the experimental vaccine for use in case of an outbreak prior to the vaccine’s licensure. The DRC becomes the first country to use these doses.

8 May 2018
Health ministry declares Ebola virus disease outbreak in Equateur Province – DRC’s ninth over the last four decades.

To support the Government’s emergency response, Gavi contributes US$ 1 million towards the deployment of health workers, transport, critical supplies and other operational costs.

May–July 2018

  • 54 cases, 33 deaths
  • Almost 3,500 people vaccinated with investigational doses of the Ebola vaccine (rVSV-ZEBOV)

24 July 2018
Health ministry declares end of outbreak

1 August 2018
New outbreak declared in North Kivu Province – considered the most complex in DRC’s history. This is the country’s 10th Ebola outbreak since the disease claimed almost 300 lives in Yambuku in 1976.

August – 11 November 2018

  • Over 400 cases recorded
  • More than 32,000 people vaccinated with rVSV-ZEBOV with Gavi support

November 2018
Gavi agrees to fund Ebola vaccination costs as part of DRC’s revised Ebola response plan.  The Alliance is also supporting 15 field-based UNICEF staff responsible for Ebola communication and prevention at community-level.

“Among their achievements, we particularly remember the [Ebola] vaccination, including in red areas, of more than 27,000 high-risk contacts, at least half of which could have developed the disease. Without the prompt and effective intervention of national and international experts, it is a drama of considerable [greater] magnitude that we would be experiencing at the moment.”
Dr Oly Ilunga Kalenga, Minister of Health, DRC


FUTURE OUTLOOK

The most effective strategy for ensuring global health security is to stop outbreaks before they occur. Strong and resilient primary healthcare systems are the foundation of outbreak prevention with immunisation as a key component. Where outbreaks do occur, more robust surveillance systems are needed to detect them early.

The ICG has generated a wealth of information to support improvements in outbreak response. However, there is an opportunity to link its activities to broader disease control initiatives through routine immunisation.

Strong surveillance systems and diagnostics are essential to quickly identifying outbreaks. Making cutting-edge diagnostic testing available and affordable in low-income countries —both in laboratories and for use in remote locations — is also critical to achieving sustainable global epidemic preparedness.

One solution is to provide incentives to manufacturers by creating markets that may have seemed impractical. Gavi is already working with industry to harness innovative refrigeration technologies with the potential to modernise vaccine cold chains in the world’s poorest countries. The global health community could look at how a similar approach can be applied to innovative diagnostic technologies.

With many diseases showing similar symptoms, highly accurate testing is required to detect an outbreak at an early stage. Given the speed with which pathogens can spread, any delay in diagnosis will ultimately be measured in lives lost. However, currently no validated kits for basic yellow fever tests are available on the commercial market, despite the risk of yellow fever epidemics across many developing countries. To address these failings, the Gavi Board agreed in November 2018 to apply market shaping efforts to the yellow fever diagnostics market.

Further reading

Feature story: Catching epidemics before they catch us


[1] Jones KE1, Patel NG, Levy MA, Storeygard A, Balk D, Gittleman JL, Daszak P. Global trends in emerging infectious diseases.
Nature. 2008 Feb 21;451(7181):990-3. doi: 10.1038/nature06536.