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Vaccine Man

Interview by Brian W. Simpson

Fifteen years. That particular chunk of time greatly bothers Orin Levine. Once the hepatitis B and Haemophilus influenzae Type b (Hib) vaccines were approved for use in wealthy countries, it took that long for them to even begin to be used in poor countries. Levine, PhD '94, director of the International Vaccine Access Center (IVAC), is committed to eliminating that kind of delay. He recognized an opportunity in the pneumococcal conjugate vaccine (PCV), which was approved in 2000 and protected against seven strains of bacteria that can cause pneumonia, meningitis and sepsis. (Second-generation vaccines now protect against 10 and 13 strains.) Starting in 2003, Levine led PneumoADIP, a pioneering $60 million effort supported by the GAVI Alliance. Its goal was to coordinate donors, vaccine makers and governments to speed PCV distribution. As a result, second-generation vaccines are being distributed in some African countries at the same time as in the U.S. and Europe. Expanded access to the vaccines will save an estimated 5 million children's lives over the next 20 years. In mid-summer, Johns Hopkins Public Health's editor Brian W. Simpson spoke with Levine, an associate professor of International Health, about PneumoADIP, vaccine pricing and his blog for The Huffington Post.

Why devote your career to vaccines?

I think the most important thing for me is that vaccines are tools for social justice. They really work well at diminishing disparities in health. Whether you're rich or poor, living in difficult circumstances or comfortable ones, when you're vaccinated, you're protected. And I find that appealing.

The history of distributing vaccines to developing countries is pretty dismal.

Until about the early '70s, only about 5 percent of the world's children were getting routinely immunized. If you think about that, we only have 30 years of experience rolling out these new vaccines. Maybe we should cut ourselves a wee bit of slack that we didn't roll out everything as fast as we would have liked.

PneumoADIP changed things. How?

It set out to accelerate development and introduction of pneumococcal vaccines in the places where they were needed the most. We played a kind of central coordinating role. We worked with the World Health Organization, UNICEF, the GAVI Alliance, vaccine manufacturers, developing countries, international financing groups and donors like the Gates Foundation or national governments. It's really a function of coordinating the actions of all of those groups.

Give us an example of PneumoADIP's impact.

Well, the vaccines started to roll out last year, but a lot of the research occurred in The Gambia. The Gambian pneumococcal vaccine trial essentially catapulted pneumococcal vaccines in the global health field because it showed that three doses of the vaccine reduced all child deaths by 16 percent, which is an incredible impact. In the Gambia trial, that was 7 deaths prevented for every 1,000 children that we vaccinated.

Did you have the sense that PneumoADIP would be a transformative project?

Yes. We knew that we had been given a golden opportunity. We knew this was probably the single best opportunity that had ever presented itself to the public sector and the vaccine community to get it right.

What are advanced market commitments (AMCs)?

Newsweek said AMC is like a carrot on a stick. It says to vaccine manufacturers, if you make safe, effective vaccines for developing countries and they're affordable, donors will buy them and pass them on to the developing countries at a price that they can afford. Industry gets its money back, and developing countries get a lifesaving vaccine. To me, it's just a smarter way to use our investments in global health. It's making sure that the developing countries get the vaccines in the formulations that they want at the prices that they need.

Why not just go with the lowest bid you get from the manufacturers?

Well, there are two things. One is you get greater supply security when you have more than one supplier. When we have only one supplier and then suddenly something happens to their manufacturing plant, we’re totally without vaccine. The other is you put a ceiling on the price. I mean the AMC says we’ll buy these from you, but you will not ever charge more than $3.50 a dose to the poor countries that are going to buy this.

Is it better to give vaccines to developing countries free or charge a small amount?

I think people are surprised to hear it but one of the major groups that pushed GAVI to charge a small amount for vaccines was developing countries themselves. If you give vaccines to them for free, they say, sure we’ll take it but they won’t be invested in it. Even a small charge for vaccine means developing countries’ governments have skin in the game. That helps to improve sustainability. It says, “We’re invested in this. We value this.”

How will things be different with future vaccines like dengue or malaria?

When we have a strong immunization system that includes financing and delivery systems and surveillance and those kinds of things, you can draw in the innovations that are coming out of research and development and deliver them rapidly. Those are vaccines that we will be able to slip into existing programs.

PneumoADIP is winding down. So you founded IVAC to apply the same ideas to other vaccines?

Within a week of our announcement of IVAC in October 2009, the phone started ringing. All these people called to ask if we would work on dengue, or malaria, or flu. It was really kind of amazing.

What are you working on now?

We are continuing to see work on pneumococcal vaccines through and adding to that some work on other vaccines. One is a vaccine against rotavirus, which is the most important cause of fatal diarrhea worldwide. We expect rotavirus vaccines to be rolling out this year and next. Another is dengue. We’re excited because we’ve got a few years before dengue vaccines are expected to be licensed. We can start coordinating and lining up, and maybe if we’re successful, we can see the launch of these vaccines in the most affected populations first, not just the ones that can afford it. We’re also trying to figure out how to use technology to improve vaccine coverage—how to use cell phones to improve the timeliness and coverage of all vaccines. You can potentially use it to track the deliveries of vaccines to the clinics. On the demand side, you can send reminders to parents that it is time to come in or that there are vaccines in the clinics.

You really have to push to get the donors, manufacturers and others to get things done. Some researchers aren’t comfortable being seen as advocates.

When we get involved in advocacy, we start with the evidence. We think that evidence-based advocacy is important because we know it is not enough for public health to generate new evidence. That evidence has to lead to changes in political will and a whole bunch of other things. We know the people who know the evidence best should be in a position to advocate for it if the evidence says that intervention should be a priority.

You’re obviously busy, yet you make time to blog for The Huffington Post. Why?

I’m coming up on a year with Huff Post. I really like it. It’s been remarkably well picked up by big groups like the Gates Foundation, GAVI, Kaiser Family Foundation and daily digests of global health stuff—those reach the people I want to reach. The thing about a blog is, when it works, it starts a conversation that was not there before.