News & Views — Vaccines: The Big Picture

In the hustle and bustle of our daily efforts, it is easy to get caught up in ordering supplies, recording temperatures, scheduling appointments, keeping records, answering questions, and the many other details related to keeping our patients, families and communities healthy with vaccines. So as National Immunization Awareness Month (NIAM) approaches, we thought it would be a good time to collectively take a step back and think about the big picture.

Let’s start at the end.

After all of the vaccines have been administered and a community’s immunization goals reached … nothing happens. Well, not really. It just seems that way. The reality is the vaccines work, and people don’t get sick. A recent paper by Brian Wahl and colleagues at the International Vaccine Access Center (IVAC), based at the John Hopkins Bloomberg School of Public Health, provides more evidence of the importance of continuing to introduce vaccines to susceptible areas and populations. The paper, “Burden of Streptococcus pneumoniae and Haemophilus influenzae type b disease in children in the era of conjugate vaccines: global, regional, and national estimates for 2000-15,” was published in the Lancet Glob Health 2018, Jul;6(7):e744-e757, and compared deaths caused by pneumococcus and Haemophilus influenzae type b (Hib) between 2000 and 2015.

Through a series of meta-analyses, the authors were able to assess the proportion of pneumonia and meningitis attributable to pneumococcus and Hib as well as other invasive outcomes (termed NPNM which stands for non-pneumonia, non-meningitis) that result from these infections. The authors then compared cases before and after vaccine introduction taking into account existing data related to vaccine efficacy, effects of herd immunity, and increases in non-vaccine types of pneumococcus in countries that used PCV7 as well as comparing HIV-infected versus HIV-uninfected differences in outcomes. The researchers found a 51 percent decrease in deaths caused by pneumococcus between 2000 and 2015, and a 90 percent decrease in deaths caused by Hib during the same period. Results were further described based on type of disease (pneumonia, meningitis, and NPNM), countries with highest prevalence, as well as in HIV-positive and HIV-negative children. Results were also analyzed based on introduction of vaccine during the study period in the countries. In the discussion, the authors made the important point that this study does not validate measures of vaccine impact in the field, but that the data do underline the importance of continuing to vaccinate. In an accompanying commentary, Cynthia G. Whitney from the CDC pointed out “Conjugate vaccines have proven to be highly effective for preventing severe pneumococcal and Hib disease in young children, and Wahl and colleagues credit most of the decline in deaths between 2000 and 2015 to vaccine implementation.”

At the beginning

We know vaccines work, not just because of data presented in the paper by Wahl and colleagues, but from data collected over years of vaccinating against many diseases. But, do you ever stop and think about all that happens in order for a vaccine to become available as a tool for protecting your patients and communities? The National Vaccine Program Office (NVPO) has identified four priorities; one of which is vaccine innovation.

In December 2017, the NVPO prepared a report for Congress related to vaccine innovation. The report included information about the current status of vaccine development, including a brief discussion of the various partners in the process as well as the role of various federal agencies. According to the report, more than 120 vaccine candidates in development aim to prevent or control more than 40 infectious diseases. Table 2 lists candidate vaccines along with information about the target, the sponsor, and the phase of development according to the Pharmaceutical Research and Manufacturers Association of America (PhRMA).

The central message of the report related to current challenges and opportunities in the arena of vaccine innovation. Challenges identified include:

• Limited understanding of the science to develop optimal vaccines
• Challenging clinical trial design for specific populations
• Converging regulatory requirements across countries
• Uncertain return on investment for new and improved vaccines

The report described each of these ideas and included opportunities to address them. Although healthcare providers do not often have a reason to consider vaccines that are not yet products, looking over the report can help provide a context for the number of organizations, scientists and studies that a candidate vaccine passes through before reaching office refrigerators.

YOU are the middle!

No matter how innovative an idea or how effective a vaccine, we could never reach the population-based outcomes we see in our communities without healthcare providers in offices, clinics, pharmacies, schools and other settings throughout the world delivering vaccines to their patients. So as we head into NIAM, take a moment to consider your role in decreasing not only the deaths caused by pneumococcus or Hib, but also all of the other vaccine-preventable diseases that you regularly vaccinate against. And, while NIAM gives us an opportunity to remind our patients and communities about their vaccine needs, let it also give us an opportunity to pause and congratulate ourselves and our teams for the everyday efforts of ordering supplies, recording temperatures, scheduling appointments, keeping records, answering questions and the many other details related to keeping our patients, families and communities healthy with vaccines.