Hi! I'm Jos Vandelaer, Head of UNICEF's Global Immunization Program. Ask Me Anything.

Since the CIA organised a fake vaccination programme in an attempt to gain DNA from Osama bin Laden and with all the associated deaths of vaccination workers in Pakistan how do you plan to overcome all the mistrust, educate locals and convince Westerners + volunteers to continue with the program?

Great question. I'd like to add what changes to trust you have seen in the field because of this.

Building trust in immunization is part of regular immunization outreach. UNICEF and partners work with community leaders and communities everywhere around the world,to build trust. It is important for communities to understand the benefits of immunization for their children, and that is a message we want to convey all the time, every where.

What's the relationship like between UNICEF's immunization project and the Bill Gate Foundation's immunization project? Do you guys work together or do separate programs?

Excellent question. I'd like to hear the answer to this too.

The Bill and Melinda Gates Foundation are one of the funders of UNICEF's vaccine programmes, from the foundation website

"Ultimately, all of our vaccine-related work depends on strong systems within countries. We therefore invest in partners whose programs strengthen and provide support for these systems; such partners include the World Health Organization (WHO), UNICEF, the GAVI Alliance, and civil society organizations."

http://www.gatesfoundation.org/What-We-Do/Global-Development/Vaccine-Delivery

Hi doodlelogic. You are correct. Immunization is a partnership, including BMGF and UNICEF, and together we are stronger.

How does the anti-immunization movement effect your work in developed countries? The MMR immunization has had trouble over the years.

Edit : I found a comic that explains where the issue over MMR came from Would you like to know more?

Hi PonderMonger, UNICEF has immuniztaion programs mainly in developing countries, but of course we are very concerned when people don't immunize their children based on misconceptions or false information. The measles outbreak in the UK and whooping cough in the US are clear indications that without immunization these diseases will strike anywhere. It is therefore essential to immunize ALL children.

What are the biggest challenges in deploying large scale immunization clinics? Are there any diseases you hope become eradicated within the next few years?

Hi! We for sure hope polio will be eradicated in the next couple of years! We have done it with smallpox, and polio is next! We are making a lot of efforts to eradicate polio, and in doing so, we are also contributing to decreasing other diseases. Organizing big immunization campaigns involves a lot of management and a lot of logistics, because you need to vaccinate millions of children in just a few days. Of course, these are just some of the challenges. Others include funding and keeping immunization a political priority.

What's the outlook on the upcoming Malaria vaccine?

Hello hithazel, The RTS,S malaria vaccine is currently being tested (i.e. not yet used in programs), and seems to protect between 1/3 and 1/2 of immunized children, depending on the age it is given. Further studies are ongoing. In broad terms the prospect of a malaria vaccine is very appealing, but the current vaccine has not yet given the results we would have hoped for.

What single social change and single policy change when implemented at a global level would have the greatest impact?

Hi AntArch, great question! There is no single intervention that would cure the world of all its problems, but immunization is certainly an intervention that has been and is enormously successful! it saves millions of lives every year, it has eradicated smallpox, and is about to do the same for polio.

How would you convince someone who believes that vaccines cause autism otherwise.

Great question. The studies that claimed there was a link between vaccines and autism have been fully discredited. There has been a very deep and thorough scientific discussion around the topic, and the conclusion is that there is no link between vaccines and autism. The diseases vaccines protect against are life-threatening. To decide not to vaccinate your child because of unsubstantiated and not scientifically-proven rumours is simply dangerous: it harms your child's health!

Hi Jos,

Thanks for doing this AMA. I've spent much of the past year designing, developing and testing a solar refrigeration system for vaccine preservation in the developing world. My question to you is in two parts:

Firstly, given that viable solar refrigeration systems already exist, just how much impact do you think a much larger, much cheaper system (for use in clinics) would have on the distribution of vaccines across the developing world?

And what are the more significant issues in the vaccine supply chain?

Thanks for your time.

Hi iamafrog, Great to "meet" someone who has been working in the field of solar refrigeration. As you know, solar refigeration can help to keep the vaccine cool in places where there is no or limited (electric) power supply. THese systems already exist, but are further being optimized - probably by people such as you!. One example is that nowadays we also have solar fridges that operate without batteries, making maintenance much easier. Significant issues in the vaccine chain are to get all the different pieces to work together: making sure the vaccine arrives in time where it is needed, at the right temperature, and in the right volumes. Have the people in place to handle and distribute the vaccine. Keep the cold chain operating at every step of the process. Stock management. Plenty of elements that need to work together....

Dr. Vandelaer,

First off - it's a pleasure to speak with you. My MSPH was International Health with a minor in Vaccine Science and Policy, and I spent a year working on vaccine policy for the US federal government before beginning my PhD in Health Policy and Demography (almost finished my first year!), so I am very interested in your work. Just check out my reddit account name... I guess you could say it's my passion :). I have a few questions:

• In the US, the anti-vaccine movement is fairly powerful, at least in the sense that it has a significant following and has been linked temporally to several outbreaks. It seems that the media just makes it worse. Giving equal (or more) air time to anti-vaccine persons as to, say, the head of ACIP. Also, several federal vaccine advisory committees have anti-vaccine persons ON THEIR COMMITTEES AS VOTING MEMBERS. I understand giving a voice to opposition, but I feel it's not safe nor fair to give voting rights to people in blatant ignorance of the mountain of evidence as to everyone else on the board (mostly experts on the science behind the policy). What are your thoughts about possible ways to improve how we communicate about vaccination and increase it's mass appeal? Do you encounter such problems in other countries?

(On a related note, in light of how powerful anecdotes seem to be in propelling the anti-vaccine culture, I think countering those anecdotes with anecdotes of parents and family members whose loved ones died or were permanently disabled from vaccine-preventable diseases, urging people to vaccinate could be effective. Serious vaccine-preventable outcomes occur at a much higher rate than do the "fake" vaccine adverse events, and especially the serious but extremely rare serious adverse events that are actually known to occur, so it seems that this could be an effective strategy).

• In the United States (and in other countries, I did my Master's thesis on this work), the rate of healthcare personnel influenza vaccination is unacceptably low, despite (in many cases) GREAT efforts to educate, make the vaccine convenient (often free), etc. It seems to be a culture issue here in the US, at least partly. In recognition of the failure of such extensive (and costly) efforts in the US, it has become increasingly popular for healthcare organizations to make the annual vaccination mandatory as a condition of employment, without exemptions (other than documented medical contraindications). This has been extremely successful, resulting in rates approaching 100% vaccination, with termination of employees occurring often at only a fraction of a percent. However, this topic still remains controversial. What are your thoughts on how to improve this issue on a larger scale? The US Supreme Court has ruled that States have the ability to mandate such things, but not the federal government (unless during a public health emergency), but so far, no states have touched it, it's just been up to individual organizations who feel proactive).

• Another influenza question - how close do you think we are to developing a universal influenza vaccine?

• One issue I struggle with is the role of the free market in vaccine research and development (especially in the US, with its patent laws). On one hand, patent laws (and free market pricing) allow vaccine manufacturers to have SOME financial security on the payout of their investments in R&D. The estimates I've heard from the US are that it costs anywhere from $100 million to $1 billion to get a vaccine from Phase I through licensure, and that less than 1 in 80 make it to licensure, so it's a risky endeavor. That being said, as we well know in the US, manufacturers have little financial incentives to invest in effective, preventive drugs/treatments in comparison to expensive medications that must be taken many times over one's life, so there is an imperfect market here. Further, we have seen examples, such as with the HPV vaccine in the US, where manufacturer price affected the ACIP's recommendation - in that case, in which the vaccine is more cost-effective in women (considering they have the additional benefit of cervical cancer prevention, which makes up a lot of the disease burden of HPV), and the manufacturers determined their market price to be cost-effective in women, but not in men. When ACIP was trying to make their recommendations, they couldn't find it cost-effective in men at the high price that was set, even though it prevents many cancers and warts in men, so they only made a passive recommendation to males. If the price were not so high, it would have been recommended to both sexes. I know there are alternative pay structures out there - the airline excise tax that France uses, GAVI's model, productRED, but wanted your insight on these matters.

Thank you for all of your work and effort. I would love to speak with you some day!

TL;DR:

• You're awesome; I love vaccines.

• The anti-vaccine movement: Possible ways to improve how we communicate about vaccination and increase it's mass appeal? Do you encounter such problems in other countries?

• Low rates of HCP influenza vaccination: how to improve on a larger scale than relying on individual institutions to make it a condition of employment?

• How close do you think we are to developing a universal influenza vaccine?

• The difficult case of making vaccine R&D more attractive: trade-offs between role of the free market/patent systems vs. regulated market vs. newer payment models... thoughts?

EDIT: added some questions EDIT 2: added TL;DR, since my questions are complicated and required a lot of text. EDIT 3: spelling/grammar

Thanks TheVaccinator! In the interest of time I am just taking your first question. It is important that people see immuniztaion as a protection for their children, and most do! Compare it to a seatbelt. Nobody puts his/her child in a car without a seatbelt. Because we all want to keep our children safe. Once people understand that, it becomes systematic. Same for vaccines. You need to get the message across that vaccines are safe, that they save lives, and are necessary.

• How are the immunization programs against polio in Nigeria and Pakistan going? I know there is some mistrust against the UN in certain regions. What do you do to convince people to immunize their children?

• For which disease do you hope a vaccine will be developed soon.

• How difficult is it to get a new vaccine approved for use in UN vaccination programs?

Thank you for answering these questions.

Hi Imwe, TAking your last question, as we have tackled the others in previous answers. Governments decide which vaccines they want to include in their own programs, depending on what diseases are main problems, their funding situation, local demand etc. However, WHO regularly reviews what vaccines are available and makes recommendations as to their use. It is up to governments to accept or not accept these.

I'm a university student in the UK hoping to go into working with immunisation in sub-saharan Africa, what would be the best thing to do in the next few years given I graduate in the next few months?

Hi SavageNorth, great career choice. I would advise trying to join an agency which works in vaccinations. UNICEF would be a great start! As you are a recent graduate, voluntary work in a relevant country would really help with your job prospects. Good luck!

What's your opinion on the recent news that vaccines can be administered without needles and much cheaper to do so?

There are some studies being done with a new generation of needle-free devices, that woulod deliver vaccine subcutaniously (just under the skin). It would alos allow to use smaller doses of vaccine, and therefore make programs cheaper. I think this is a promising development, but more research is needed.

From what I understand, in developing countries, it is much easier to procure funding for vaccines themselves rather than the resources to safely store, deliver and administer these vaccines.

This leads to horror stories of vaccines expiring in overflowing central warehouses (because there isn't an adequate system to store or transport them and it would not be politic to decline the donations) or being handled improperly such that they've gotten warm (which is likely detected causing them to be thrown out) or frozen (which is far less likely to be detected causing an ineffective vaccine to be administered).

What is UNICEF doing to make this better?

disclosure: my day job is helping people find ways of making some of the existing distribution networks more efficient.

UNICEF is for the most part a purchaser, and woks closely with other organizations. The WHO has a program that pre-qualifies vaccines for manufacture and distribution, based on certain criteria. There are definitely incentives to generate vaccines that are stable at ambient temperatures within these programs-- supporting the production of a particular type/character of vaccines is often the best way to direct research. Supply and demand.

http://www.who.int/immunization_standards/vaccine_quality/pq_system/en/

UNICEF only procures "WHO-prequalified" vaccine, as vaccinethrowaway"has said. This means that all vaccine that UNICEF purchases is of assured quality. But of course, once purchased, the vaccine needs to be transported and stored in a functioning cold chain. Also here UNICEF helps countries that request its assistance to make ongoing improvements to their supply systems.

How do you ensure stuff like this doesn't happen in the future:

Sorry: US Apologizes for Syphilis and Gonorrhea Experiments on Guatemalans

US researchers infected patients with STDs without their consent in the 1940s

This is why ethics committees now exist. Very specifically. While it is important to recognize that researchers and funding agencies should be held accountable for their past mistakes, precautions have been put in place to prevent these sorts of atrocities from ever happening again. Doing human trials takes literal Years of prior research and work, which is part of the reason drugs/vaccines often cost so much (whether or not it is justified is another story).

Fully agree with this response.

what country ( or area/region) of the world do you feel needs the most assistance and attention right now?

Globally, over 20m children are not being immunized, and 70% of these live in just 10 countries, including India, Pakistan, Nigeria, to name a few. We need to give these countries more attention and support, so that more children get immunized.

How do you think the new "micropatch" vaccinations will change what you do?

Hi Gimmeacookie,

It's an interesting development but it is just too early to say. We can say though that it doesn't change the biggest challenge - getting the vaccine to the child - although it will make the act of vaccination easier and reduce the waste stream.

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Thanks, jcmancin. We think it is outragious that health workers are being attacked. They are at the forefront of bringing vital services to children, including immuinzation. Their safety needs to be guaranteed. Also part of our work is educating communities on the importnace of vaccinating children. We are also strengthening the links between the communities and the health workers, for example by employing health workers from the area where they work and involve them in community discussions. In addition, we are delivering more services with immunization, such as Vitamin A, deworming tables, and in some place mosquito nets...

What diseases (et al) do you think we can see eradicated in our lifetime? & maybe even reasonable time-estimates on when that'd happen

Polio by end 2014 is our target!

How much does the head of UNICEF get paid?

The undersecretary general earns USD$189,349 gross, per the salary scale available here.

In general, you can always find out the pay of public officials and salary executives if you're willing to spend a bit of time researching.

I thought so. Some stupid FB thing going around saying he/she earns 600K.

Hi ProbablyProne, there have been a few urban legends floating around the Internet about UNICEF USA's executive pay. I encourage you to share this link with your friends to help debunk it: http://www.unicefusa.org/about/faq/ceo-salary.html