Pneumococcal vaccine, a debt trap for poor countries? Is treating pneumonia more economical than vaccinating?

Jul 28, 2009 3:43 amRecently there have been a number of articles critical of the recommendations for pneumococcal and the pentavalent vaccines in high impact journals. I understand some of this has spilled over to the lay press and it will be good if we can have clarity on these issues.

1. Relates to the pneumococcal vaccine and the pentavalent vaccine.
(Dabade et al., The Lancet, 27 June 2009; 373:2195-6.)

The main argument seems to be that the WHO effort of promoting the pneumococcal vaccine in developing countries by entering into Advance  Marketing Commitments (AMC) with the manufacturers (to make the vaccine affordable in poor countries) is actually squandering the funds donated by philanthropic governments and individuals for the achievement of the MGD. This is because the vaccine only reduces 3.6 cases of pneumonia per 1000 vaccinated (according to Madhi et al in the Oct 2008 issue of Bull WHO). Vaccinating 1000 children costs $250,000 and treating 4 cases of pneumonia with Septran will cost $1.There are more cost effective interventions that will yield better returns for the use of $250,000 of MGD funds. We are aware that GAVI purchases vaccines for $7/dose or $21 per child. At these costs the price of avoiding 4 cases of pneumonia is $21,000. Even this appears very steep.

On the face of it, this argument seems difficult to refute. Surely I am missing something here. Does anyone in this discussion group know how to counter this argument?

2. Also this Lancet article quotes a GAVI evaluation that shows that prices of the pentavalent vaccine went up after GAVI funding.
(Kamara L, et al Strategies for financial sustainability of immunization programs: a review of the strategies from 50 national immunization program financial sustainability plans. Vaccine 2008;26:6717-26)
Projections of the UNICEF show that even into 2010 the prices may come down from $3.40 by about 10c only. The argument here is that GAVI funding used to induce governments to introduce the vaccine is something of a debt trap.

3.This also relates to pneumococcal vaccine: [Mathew JL, Pneumococcal vaccination in developing countries: Where does science end and commerce begin? Vaccine 27 (2009) 4247-4251]. It discusses the WHO recommendation on the pneumococcal vaccine and what WHO considers 'evidence of the disease burden' enough to merit vaccination.

This is what the WHO recommendation states:

"WHO considers that it should be a priority to include this vaccine in national immunization programmes, particularly in countries where mortality among children aged <5 years is >50/1000 live births or where >50,000 children die annually." (No authors cited. Pneumococcal conjugate vaccine for childhood immunization -- WHO position paper. Wkly Epidemiol Rec 2007; 82:pp. 93-104.)

The author points out that the first criteria of under-five-mortality >50/1000 live births was met by 32 countries but the total population to be vaccinated was 18 million.  By including the criteria dependent on population size of 'where >50,000 children die annually' only 7 additional countries were added, but it added 161 million to the numbers eligible for vaccination (in populous countries of India, China and Brazil). The WHO recommendations seem dictated by needs of increasing demand for vaccines and profits for manufacturers rather than the needs of public health.

There must be a strong reason why WHO made use of the second criteria, and that is not related to trying to increase the demand for vaccines but it is not clear. Discussion on this site will help clarify matters.
I will be thankful if I get more clarity on this issue.

Thanks and regards,

Dr. Omesh Bharti
Directorate of Health Services
Himachal Pradesh