The Journey of a Vaccine

October 12, 2010

Life-and-death decisions are not usually made by a mother buying nappies on a suburban high street. She may not even know that the choice could set in motion a complicated chain of events, stretching around the world, that will directly affect other women, such as Madame Akam Justine, who swats away mosquitos to deliver scores of babies on the floor of her small brick home in a remote village in Cameroon.

The work of women like Madame Justine, a traditional birth attendant favoured by women too poor, or far away, to use a hospital, is often makeshift, rudimentary and tainted by tragic conclusions. It has also never been higher on the international agenda. Reducing maternal and child mortality is one of the key UN Millennium Development Goals, and what works best is vaccination against epidemic diseases.

In Cameroon Madame Justine is preparing to play her part in a global vaccination campaign by Unicef to eradicate maternal and neonatal tetanus. For the past five years that campaign has been conducted in the UK in partnership with Pampers, which donates one tetanus vaccine for every pack sold between October and December.

But before that vaccine can be injected into a woman’s arm it circles the world on a precarious journey — passing though the hands of aid agency strategists, scientists, West African bureaucrats and volunteers on rickety motorbikes.

In New York the first stage of the process is overseen by Rownak Khan, Unicef’s senior health specialist. Dr Khan has worked on vaccination campaigns across the world, using ingenuity, as well as medical knowledge, to find ways of reaching flooded villages in Bangladesh and negotiating with tribal Afghan men so that untrained women can vaccinate their peers with specially adapted syringes. For the past ten years she has been working to eliminate tetanus, a silent killer in the developing world, which has languished as a low priority in the health community. “Tetanus is not a visible problem because it’s happening in remote areas among people with no political clout,” she says.

To date 100 million women have been vaccinated by the Unicef campaign, but the disease, which develops if bacteria enter the bloodstream during childbirth, will still claim the lives of 60,000 babies this year.
After collecting and analysing health data from 58 countries, Khan’s team makes a difficult estimate about how many women need the vaccine and place an order from four international laboratories. The vaccines destined for Cameroon are produced in the National Health Institute of Bulgaria, a hulking building in downtown Sofia that was originally erected by the Rockefeller Foundation.

Lina Bineva has worked at the institute for 40 years and now leads the team of 50 technicians who produce the vaccine. She explains that the tetanus bacteria was first identified by a Japanese scientist, Kitasato Shibasaburo, in late 19th-century Berlin. A vaccine was then quickly developed to treat soldiers suffering from deep tissue wounds in both world wars. What reaches patients today is the stable and effective “Harvard strain”, developed by scientists in Massachusetts in the 1950s. Over a period of five months the tetanus bacteria is grown, de-toxified and then concentrated as a toxoid solution. When a batch is finally signed off, thousands of doses enter the temperatur-controlled “cold-chain” process and are flown out of Sofia to warehouses around the world.

In Cameroon the vaccines are unloaded in the hilly capital city of Yaounde and moved to a central depot before being transported by truck to regional health centres, such as Nguelemendouka, close to Madame Justine’s village. The chief medical officer, Dr Wassep, takes charge of the 12,000 doses and stores them at the local hospital. The vaccines are kept in a small room lined with wooden shelves, and maintaining the supply of gas bottles to power a series of domestic fridges is the first in a series of problems that Dr Wassep faces.

If he is successful, and the temperature is preserved, the vaccine can be handed over for the final stage of the journey, in which regional outreach workers precariously strap the cold-boxes on to motorbikes and head across rural, and often waterlogged, roads. Any disruption can have fatal consequences. Sophia and Nkodo Isodore lost their newborn grandson to tetanus: “We made sure our daughter received the first dose of the tetanus vaccine but the motorbike from the outreach service broke down the day it was due to visit our village to give her the second dose, so she never received it before she suddenly gave birth.”

The Isodores rushed the baby to hospital when he stiffened and changed colour. Despite a week of medical care, he could not be saved. Dr Wassep said: “I don’t believe I have been able to save one baby from newborn tetanus.”

In a country such as Cameroon the village is the front line of healthcare, and winning the co-operation of women like Madame Justine is vital before any vaccination campaign can succeed. Birthing attendants often operate in small hamlets in the rainforest, with only a thin dirt road connecting them to the nearest neighbour. Hospitals are a remote and expensive luxury, where giving birth can cost $6, rising to $30 if there are complications, and where women must pay for their own painkillers (only paracetamol or ibuprofen are available). As a last resort, birthing attendants sometimes rush emergency cases to the local medical centre, pushing pregnant women as far as 20 miles in a wheelbarrow. Even if they make it, the prospects for survival are bleak.

Madame Justine admits that she has no formal training. She says that when women come to her house to give birth “they must come with their own materials, all the things they need for birth; razors, gloves, alcohol”. If the women do not have a new razor blade Madame Justine heats an old one over a flame. If they don’t bring gloves, she delivers the baby with her bare hands. And Madame Justine’s procedures are more hygienic than many — some traditional birthing attendants delay labour, or speed it up, with herbs, use eau de cologne as a disinfectant and then cut the umbilical cord with a piece of sharpened bamboo.

If procedures like this enable tetanus to enter the bloodstream, superstition and local myth mean that it often flourishes undiagnosed. Sophia Isodore admits that, at first, she did not understand her grandson’s illness: “I didn’t know whether he was suffering from tetanus or witchcraft.”

Dispelling those beliefs, and improving education, is the other function of local outreach workers. Desire Endondo is a volunteer outreach worker for Unicef and rides from village to village. He hosts his own radio show, talking about health problems, and deafens locals by gathering them together in a small room and barking instructions about the vaccination campaign through a megaphone. The megaphone has been provided as a communication tool, and Desire’s attitude is, if you have it, use it. He discovers that the women have many reasons for not wanting the vaccine. One lives on a remote farm that outreach workers did not know existed. Another says: “I was afraid the needle would break off in my arm.” There are widespread rumours that babies develop a fever. Some families simply do not know about the dangers of tetanus.

Most women are persuaded, eventually, to have the vaccination, and Desire issues each with a booklet. Desire carefully records the results on paper and gives the information to the hospital and then to Dr Khan in New York. But the tetanus vaccination is a three-stage process and it’s hard to monitor whether all these women will ever be fully protected.

The journey of the vaccine has been complicated and long. It has taken a precarious passage, beginning on a UK high street, and threatened by unreliable gas supplies, motorbikes that stutter to a halt and a paper chain of data stretching halfway across the world. At the end of it, however, Dr Khan estimates that 80 per cent of the women of Cameroon, and their babies, have been protected from tetanus — which seems remarkable in a country where one in seven children will still die before he or she is 5.

There are often criticisms levelled at the aid community, Dr Khan acknowledges, and some may be justified. But the vaccination campaign remains a gold standard for health work throughout the world, and if they stopped tomorrow, Dr Khan says, “I guarantee you there would an epidemic of disease — and all of our good work would be lost.”

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