Making vaccines work
In the coming weeks, Grade 4 and 5 schoolchildren in selected regions will start receiving Dengvaxia®, the new vaccine for dengue fever.
As we hail this vaccine as a public health milestone, it will be insightful to reflect on the long history of vaccines in saving lives, and the challenges health officials have faced in making them work.
It was in 1796 when an English doctor, Edward Jenner, established the idea of vaccination by proving that children can be protected from smallpox by exposing them to the similar but much milder virus called cowpox. Just seven years later, a Spanish doctor, Francisco Xavier de Balmis, embarked on a remarkable expedition to bring the vaccine to the Americas and the Philippines, reaching our shores in 1803. Joining him were 25 orphan boys from Mexico who carried the vaccines in their bloodstream—the only known method of transporting the vaccines at the time.
Other vaccines eventually followed, including rabies (1885), tetanus (1927), polio (1955), and measles (1963). In 1971, the MMR (mumps, measles, rubella) vaccine combined mumps, measles and German measles vaccine, making vaccine delivery much more convenient. In 2006, the HPV (human papillomavirus virus) vaccine was released—a breakthrough that can help prevent cervical cancer.
A vaccine against one of the dengue strains was actually developed as early as 1946. But what made a dengue vaccine particularly challenging is the fact that there are four strains of dengue, and having immunity for one strain can potentially make the infection with another strain even worse. Thus, it had to be a vaccine for all four (“tetravalent”) strains—or nothing. Fortunately, advances in biomedical research finally caught up with this challenge, and in December 2015, the Philippines became the first Asian country to approve the dengue vaccine, developed by Sanofi Pasteur.
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But challenges remain in making vaccines work. In the wake of Typhoon “Yolanda,” measles outbreaks in Metro Manila caused a number of deaths, underscoring the fact that not all Filipino children receive vaccines. The 2015 National Nutrition Survey raises a worrisome statistic: We are seeing the lowest rates of immunization among children in the last 25 years —61.9 percent compared to 71.5 percent in 1992 and 79.5 percent in 2008.
This drop can be explained by a number of reasons. In the first place, there are cultural barriers that have made parents unreceptive to the idea of getting vaccines. In some parts the Philippines, this may be linked to the general distrust of biomedicine and a resistance to any kind of needles or syringes piercing the body—a “disruption” that is seen to have spiritual consequences. Many studies cite “cultural reasons” for nonvaccination—but we need to study these reasons if we are to fine-tune our messages to respond to them.
Misconceptions come, not only from traditional beliefs alone, but also from modern-day conspiracy theories. In the United Kingdom, a paper linking measles vaccines with autism— forcefully discredited by many scholars—had the unfortunate consequence of leading many parents to choose not to have their children immunized; their decisions have been linked to increased deaths from measles. In parts of Africa, beliefs linking polio vaccine to infertility have caused the resurgence of a disease that’s otherwise close to eradication.
We can interpret these misconceptions as part of people’s mistrust in their government, and in what some of them might call the “new world order.” In many other cases, however, misconceptions are spurred by the fact that vaccines do fail. Sometimes they can present with side effects, which can make people think that they’re actually harmful. Sometimes, they don’t work: With its 56.5 percent efficacy, the dengue vaccine can disappoint those who still acquire the disease despite having been vaccinated. These cases, especially when they are magnified by word of mouth and sensationalized in the media, can dissuade parents from getting their children vaccinated.
Still, the most significant barrier is the inaccessibility and unaffordability of the vaccines themselves. The Department of Health provides free vaccinations for children under its “Expanded Program on Immunization,” but implementation has been compromised by budgetary constraints and supply issues. The dengue vaccine alone, for instance, is estimated by the DOH to cost P3,000 per child—amounting to P3 billion for the initial 1 million children targeted. The alternative—going to private clinics—remains prohibitively expensive for most Filipinos. While it is understandable that pharmaceutical companies need to recoup their investments, the government should flex its negotiating arm to get the best deal from these companies, and devote more resources to the acquisition of vaccines.
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From the time of Balmis’ historic voyage to the present, vaccines have saved many lives in the country. Smallpox killed over 65,000 Filipinos in 1918-1920, but since 1980, it has been completely eradicated. As researchers race to develop vaccines for emerging diseases like Zika, and enduring ones like HIV/AIDS, we have reason to hope that some of our most feared diseases will be gone in the future.
But vaccines can only work if they are accessible, affordable and culturally acceptable to the public. While the dengue vaccine is a welcome addition to our armamentarium, much work remains if we are to realize the full potential of vaccines to save lives.
Gideon Lasco is a physician and medical anthropologist. Visit his website on health, culture and society at www.gideonlasco.com.
