Features Friday, October 10, 2014 - 05:30
The News Minute | September 30, 2014 | 02:54 pm IST Olivier Charmeil brings health home in ways that are uncommon in the world of public health where leaders and politicians speak about disease and disabilities as if it happens only to others, away from them, in far away places. His conversation is peppered with references to his family, his children - all children. President and CEO of Sanofi Pasteur, the world's largest manufacturer of vaccines, Charmeil spoke to Chitra Subramaniam, Editor-in-Chief of The News Minute about eradication of polio and threats to it, competition and policy equations, the role of the media and political will which he says is among the most important factor in any public health struggle. "I don't think our grand children and their children will forgive us if we fail to protect them with the right vaccines at the right time," he says. Excerpts. The WHO goalposts for eradicating polio have been shifting. Earlier it was in the year 2000, now it is 2018. Do you think the new goal is a realistic one? This question will be settled in a few places in the world - mostly in Afghanistan, Nigeria and Pakistan and in countries that are vulnerable to transmission from those states. I am not an epidemiologist and I don't have access to the latest field information from each country. I do, though, have faith in the Global Polio Eradication Initiative and in the WHO. They have set out a clear road map to the 2018 eradication target. There are great challenges and we must work together to overcome those challenges. The date does matter but the principle matters more. GPEI commissioned a study a couple of years ago that illustrates the alternative to eradication. There would be over 200,000 cases of polio a year spread out across the world. If I were only a businessman, maybe I would look at that with equanimity: after all, in a world with lots of polio, there would be a very strong demand for polio vaccines. But as a father and a human being, I am horrified by this thought: imagine our grandchildren living in terror of a disease that we could have eradicated? One of the reasons I love leading Sanofi Pasteur is that the instinct of everybody here is to think as humans first and business people only when a sustainable business is linked to good policy. Is the Sabin (OPV) versus Salk (IPV) debate closed or do you see a parallel track as countries, mostly developing ones, transit from the former to the latter? Actually, both vaccines are now joining forces, since they are to be used complementarily in the countries where eradication remains challenging. It is important to take in account the dimension of Polio Eradication. As a universal (global worldwide) initiative, it must rely on tools having given their credit for safety and massive scale of production, which is the case of Salk IPV. Today, Sanofi Pasteur is focused on providing significant quantities of high-quality, affordable intramuscular Salk IPV to support GPEI’s Endgame Strategic Plan by 2018. We believe that the standard of care for polio immunization will be through the use of IPV vaccine and, as time goes on, through IPV-based pediatric combination vaccines, as is currently seen in many developed countries. India is making the transition from IPV to OPV soon. What are some of the pain points for a country of India’s size and diversity? Obviously, it will be a challenge as vast as the country. Don't underestimate India, though. In 1985, there were thought to be 150,000 polio cases a year in the country. Even in 2009, there were over 700. Yet, just four years later, India was declared polio free. It was once said that efforts towards eradication would be impossible because of India; in fact, it is now possible because of India. Which are some of the successful international models (combination) that serve as a reference for the transition? I think it would be a bit presumptuous of me to try to tell India where to look for models. Government will decide the pace at which it wants to introduce IPV and we will support them as a public health partner. As you reported last week, Nepal has just introduced IPV into its routine immunization system and we were very proud to be the partner there. Perception of safety (rumors, concerns) and speaking to them is a challenge. What are you doing to address this issue which is primarily one of communication? IPV is a very safe vaccine. It is used all over the industrialised world. Virtually every child in North America and Western Europe gets a combination vaccine which includes IPV. My children got IPV containing combination vaccines. Every doctor I know has given their children IPV or IPV-containing vaccines. Even the craziest vaccine denier tends to give their child IPV -- maybe their parents and grandparents remind them of what the world was like before polio vaccines? The overall question of rumors about vaccines is a very real concern. We live in a world that my great grandmother could never have imagined. No child ever need to suffer again from many of the diseases that used to kill millions and cripple tens of millions. Millions of adults are protected from influenza which used to kill both the vulnerable and the very strong. Somehow some people have convinced themselves that this is a bad thing. As I get my flu vaccine every year, I wonder why anybody could challenge the fact that vaccines represent the best aspects of medical progress. IPV needs syringes and needles. How are you addressing some of the supply-side issues? We work very closely with governments to understand their vaccine needs and to supply vaccines. It takes over 20 months from starting to produce an IPV batch to finishing it. In that time, governments can usually define their needs for syringes and needles. Most governments have established procedures for procuring these, either through their own channels or through multilaterals. We are happy to work as part of planning groups or other consultative mechanisms. Cost is an issue and the IPV is more expensive. How do you propose to come in on this critical dimension for developing countries? The cost of IPV represents less than 10% of the GPEI Financial Resource Requirements through 2018; OPV campaigns, much more. As a rule, Sanofi Pasteur supports a tiered pricing approach which differentiates prices amongst countries with different levels of income. GNI/capita serves as a key reference. The benefit of differential pricing for IPV is that lower prices be secured for GAVI countries and progressively higher prices for progressively higher income populations. Sanofi Pasteur and the Bill & Melinda Gates Foundation announced in February a joint price support mechanism, including a financial contribution from both, to support rapid, widespread adoption of IPV by Gavi-eligible countries. Moreover, we believe the long-term solution is the use of IPV-containing combination vaccines in routine immunization programs. This will reduce overall cost of vaccination, not only for polio, but also for several diseases at the same time. In this respect, IPV in combination will be more part of the solution of global routine immunisation, than an issue. Considering the enormity of the task – and production capacities – do you see India’s Serum Institute as a competitor or partner? Following WHO’s recommendation that more than 120 OPV-using countries should introduce at least one dose of IPV by the end of 2015, the global need for IPV is expected to increase dramatically in the coming months and years – and again when some of these countries will want to include a second dose, or more, in their immunization schedule. Being able to serve the children of every country in the world is a real challenge. Sanofi Pasteur has invested a lot to be in a position to serve a large part of this demand. But of course there are other vaccine manufacturers and such an effort to eradicate polio will call upon all manufacturers to bring significant production capabilities. SII is a competitor, and this can be seen as beneficial for the community. Having multiple sourcing for IPV can only be seen positively for the goal of eradication. Polio eradication has been a story of partnership, from the very beginning of the initiative, and we are convinced it will remain in the future. Despite millions of dollars poured into some regions by multilateral and bilateral agencies as well as private foundations, polio and other diseases which should have been wiped out are staring at us in the face suggesting that there’s more to eradication than money. What are some of these factors? You are absolutely right: money matters but it is not enough. The kind of political will that we saw to defeat polio in India is vital. Of course, a strong and professional immunization administration is vital as is professional support. I think the role of Rotary International in ending polio, such as the key role the Female Community Health Volunteers played in Nepal, show just how much can be achieved by civil society. Diseases do not stop at borders so international efforts need to be coordinated and focused by groups such as UNICEF and the WHO. But as in any vaccination program, the alpha and omega is about political will. - in the etymological dimension: the will of the city, of the population. Vaccination is at the service of the population; unanimity and adhesion to programs, political decision for a priority and for implementation remains among the key elements for success. India is now polio free, but there has been an outbreak in the region including in Pakistan with whom we share a border. How serious is this threat? Polio anywhere is a threat to us all. All the models show that polio will spread from any country where it can find a safe haven. At first, it may just spread to neighboring countries but very soon it will spread around the world: look at the cases in Syria this year that have been linked back to Pakistan. Our job is to make sure that we are partners in ending polio everywhere and forever. This is why IPV together with OPV is critical. The reinforcement of routine immunisation is a critical factor for consolidation of the immense gain of having achieved India as polio free. On another note, how soon will you introduce your dengue vaccine? Availability of the vaccine is anticipated end of 2015, provided it receives a market authorization. Sanofi Pasteur's objective with its dengue vaccine is to have a significant impact on public health in endemic countries. Countries’ decisions to use the vaccine will depend on many factors, including the disease burden, the time taken to license the vaccine and their ability to implement meaningful vaccination campaigns. Will it be a polyvalent one? The vaccine is against dengue only, against the four dengue serotypes. It is not combined with other vaccines. Is the dengue vaccine going to be country specific or one for all countries? As dengue serotypes circulates globally, between endemic regions in Latin America and Asia, it is the same vaccine for all countries. As a world leader in the pharmaceutical industry and research, what would you tell health ministers from developing countries that look at national health budgets as a cost rather than an investment? I would remind them of Nelson Mandela’s words: “Vaccination is a benefit to mankind”. What in your view on the role of media (mainstream and social media) as a partner in public health? Media have three vital roles to play in creating a world without polio. First, media like yours can make sure that policymakers keep this at the very front of their minds. The end of polio is in sight but we could still change course disastrously so it is important that, among all the competing priorities, policymakers stay focused on polio. Second, mass media can be highly effective in reminding parents of the very real threat from polio. There are anti-vaccine extremists with all sorts of agendas: some are linked to terrorist groups such as the Talibans; some want to see society revert to some primeval fantasy world; some are genuinely confused and misguided. By exposing their scare mongering to close examination, media can combat the insidious influence of anti-vaccine propaganda. Third, social media can show parents that the vast majority of their neighbors and of the people they know and respect are enthusiastic about protecting their children from deadly and crippling diseases such as polio. The great strength of social media is in building community momentum. Dr. Margaret Chan, head of the World Health organization (WHO) has said she does not speak to the media. She said this at the WHA last year and again this year. Comments? I am not sure what Dr Chan said and I haven't seen these reports so I can't comment. For my own part, I am delighted whenever journalists and bloggers take an interest in infectious diseases and how we can prevent them. I am extremely proud to lead Sanofi Pasteur and I want to share my enthusiasm whenever I can.
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