Leadership in global health: the case of Ciro de Quadros, a testament to values, valor, and vision

[ABSTRACT]. When Dr. Bill Foege wrote “When Words Fail,” he was referring to how difficult it was for him to describe adequately, in written words, all the effort that is involved from the scientific conceptualization of a new vaccine, to eventual bench discovery and development, to the training and supply chain logistics, and ultimately to the moment the needle pricks the skin to save a life of a child (1). He called it the “chain of perfection”. He was “at a loss” to describe this cascade of events with due justice. I have been asked to describe the leadership attributes of Dr. Ciro de Quadros as a case study in best practice and lessons to be learned. Similarly, I too am at a loss. Simply put, Ciro broke the mold. I should disclose that what I am about to write is influenced by decades of either working directly for Ciro, as was the case during the polio eradication era in the Americas, to collaborating with Ciro more recently on various projects that included measles and rubella elimination, the introduction of new vaccines, and surveillance of infectious diseases. The work evolved into a relationship that bridged from professional mentorship, to actual friends with a deep sense of admiration, love, and mutual respect. In global health, leadership is somewhat like the “self-actualization” of public health practice. The “leader” must have all those attributes that embodies a fully realized individual, positioned in the system to make things happen, such as in Ciro’s case, to help create a world of equitable access to life-saving vaccines. Ciro always kept such a vision in mind. He was unrelenting when seemingly unsurmountable forces impeded his way. Like a hurricane, he would uproot naysayers, but with a clear sense of knowing exactly where he was going. I will attempt to describe what made Ciro this “force of nature”, including, perhaps, what arguably may have been some of his deficiencies. The three “V’s”, values, vision, and valor, have been used to describe broadly the attributes of effective leaders. For Ciro, volumes could be written on each, especially if we think of his career in its entirety, spanning more than four decades.

[RESUMO]. Quando o Dr. Bill Foege escreveu “When Words Fail”, ele estava se referindo ao fato de que para ele era difícil descrever adequadamente, com palavras, todo o esforço envolvido desde a conceitualização científica de uma nova vacina, passando pela descoberta e desenvolvimento no laboratório, treinamento e logística da cadeia de suprimento até, finalmente, o momento em que a agulha fura a pele para salvar a vida de uma criança (1). Ele a chamava de “cadeia da perfeição”. Ele “não tinha palavras” para descrever essa cascata de eventos de maneira adequada. Pediram-me para descrever os atributos de liderança do Dr. Ciro de Quadros como um estudo de caso em boas práticas e lições a serem aprendidas. Do mesmo modo, eu também não tenho palavras. Em resumo, Ciro é um cara fora de série. Devo confessar que este texto é influenciado por décadas de trabalho direto com Ciro, como aconteceu durante a era de erradicação da poliomielite nas Américas, e colaboração com Ciro recentemente em vários projetos que incluíram a eliminação do sarampo e da rubéola, introdução de novas vacinas e vigilância de doenças infecciosas. O trabalho se transformou numa relação que passou de mentoria profissional a amizade, com um profundo sentido de admiração, amor e respeito mútuo. Na saúde global, liderança é algo como a “autorrealização” da prática de saúde pública. O “líder” deve ter todos os atributos que caracterizam um indivíduo plenamente realizado, posicionado no sistema para fazer com que as coisas aconteçam, como no caso de Ciro, para ajudar a criar um mundo de acesso equitativo a vacinas que salvam vidas. Ciro sempre teve em mente essa visão. Ele era incansável quando forças aparentemente insuperáveis bloqueavam seu caminho. Como um furacão, ele afastava as pessoas do contra, mas com um sentido claro de saber exatamente para onde estava indo. Tentarei descrever o que fez dele essa “força da natureza”, inclusive, talvez, o que pode ter sido uma de suas deficiências. Os três “vês”, valores, visão e valentia, têm sido usados para descrever amplamente os atributos de líderes efetivos. No caso de Ciro, podemos escrever tratados sobre cada um deles, especialmente se pensarmos em toda a sua carreira, que cobre mais de quatro décadas.

The past, present, and future of immunization in the Americas

The Pan American Journal of Public Health recognizes with appreciation the contributions of the members of the Editorial Committee, and authors of the Overview article. Their contributions and dedication to this issue on immunization in the Region of the Americas were extraordinary and helped make the manuscripts more interesting, more accurate, and more useful to our readers and all others who work to improve the health of the peoples of the Americas. The Journal would like to give special thanks to the General Coordination of the National Immunization Program, Department of Transmissible Disease Surveillance, Health Surveillance Secretariat, Ministry of Health, Brazil, whose financial and programmatic contributions were essential to the publication of this special issue.

Knowing the scope of meningococcal disease in Latin America

[ABSTRACT]. Opportunities for strengthening surveillance of meningococcal disease exist between and within countries in Latin America. In August of 2015, a workshop was convened in the city of São Paulo, Brazil, to address the following objectives: 1) to review meningococcal disease burden and vaccine use in Latin America; 2) to evaluate the effectiveness of current meningococcal surveillance practices in the region; 3) to identify challenges to meningococcal surveillance in the region; and 4) to outline steps for strengthening meningococcal surveillance and disease control in the region. Based on the workshop’s discussions, recommendations for strengthening surveillance and controlling meningococcal disease in Latin America focus on improving: a) laboratory capabilities for diagnostic testing; b) communication regarding epidemiologic- and laboratory-based analyses; c) communication during outbreaks; d) monitoring of long-term disease outcomes; e) knowledge of vaccines against serogroup B disease; and f) criteria for defining and controlling meningococcal outbreaks. Overall, improving surveillance will help guide strategies for meningococcal disease prevention and control in Latin America.

[RESUMEN]. Existen distintas oportunidades para reforzar los procedimientos de vigilancia de la enfermedad meningocócica entre los países de América Latina y dentro de ellos. En agosto del 2015, se llevó a cabo un taller en la ciudad de São Paulo (Brasil) en el que se trataron los siguientes puntos: 1) examen de la carga de la enfermedad meningocócica y el uso de la vacuna en América Latina; 2) evaluación de la eficacia de los actuales procedimientos de vigilancia de la enfermedad meningocócica en la región; 3) especificación de los retos para la vigilancia de la enfermedad meningocócica en la región; y 4) definición de los pasos para fortalecer los procedimientos de vigilancia de la enfermedad meningocócica y el control de esta enfermedad en la región. Como resultado del taller se formularon recomendaciones para reforzar los procedimientos de vigilancia y control de la enfermedad meningocócica en América Latina que hacían hincapié en mejorar: a) las capacidades de laboratorio con respecto a las pruebas diagnósticas; b) la comunicación sobre los análisis epidemiológicos y de laboratorio; c) la comunicación durante los brotes; d) el seguimiento de las consecuencias de la enfermedad a largo plazo; e) el conocimiento sobre las vacunas contra la enfermedad causada por el serogrupo B; y f) los criterios para definir y controlar los brotes meningocócicos. En términos generales, la mejora de los procedimientos de vigilancia ayudará a delinear las estrategias para la prevención y el control de la enfermedad meningocócica en América Latina.

[RESUMO]. Existem oportunidades para o reforço da vigilância da doença meningocócica entre os países e em cada país na América Latina. Em agosto de 2015, foi realizado um seminário na cidade de São Paulo, Brasil, com os seguintes objetivos: 1) avaliar a carga da doença meningocócica e o uso da vacina na América Latina; 2) avaliar a eficácia das atuais práticas de vigilância da doença meningocócica na Região; 3) identificar os desafios para a vigilância meningocócica na Região e 4) definir medidas para reforçar a vigilância da doença meningocócica e o controle da doença na Região. Partindo dos debates realizados durante o seminário, foram feitas as seguintes recomendações para reforçar a vigilância e o controle da doença meningocócica na América Latina, dando-se ênfase a melhorar: a) a infraestrutura laboratorial para exames diagnósticos; b) a comunicação das análises epidemiológicas e laboratoriais; c) a comunicação nos surtos; d) o monitoramento dos desfechos da doença a longo prazo; e) o conhecimento sobre as vacinas contra o meningococo do sorogrupo B e f) os critérios para definir e controlar os surtos de doença meningocócica. Em geral, a melhoria da vigilância contribuirá para orientar as estratégias para prevenção e controle da doença meningocócica na América Latina.

National legislation and spending on vaccines in Latin America and the Caribbean.

This study examined the dynamics of vaccine spending and vaccine legislation in the Americas Region over the period 1980-2013. Annual vaccine expenditures from thirty-one countries were extracted from the Pan American Health Organization Revolving Fund database. Information on vaccine laws and regulations was provided by the PAHO Family, Gender, and Life Course Unit. Both time series and event history models were estimated. The results show that passing an immunization law led a representative country to increase its vaccine spending, controlling for income, infant mortality, population size, and DPT3 vaccine coverage. Countries with higher vaccine coverage were also more likely to have passed laws. Conversely, higher income countries were less likely to have vaccine laws. Vaccine legislation will likely play a similarly important role in other regions as more countries move towards immunization program ownership.

Knowing the scope of meningococcal disease in Latin America.

Opportunities for strengthening surveillance of meningococcal disease exist between and within countries in Latin America. In August of 2015, a workshop was convened in the city of São Paulo, Brazil, to address the following objectives: 1) to review meningococcal disease burden and vaccine use in Latin America; 2) to evaluate the effectiveness of current meningococcal surveillance practices in the region; 3) to identify challenges to meningococcal surveillance in the region; and 4) to outline steps for strengthening meningococcal surveillance and disease control in the region. Based on the workshop's discussions, recommendations for strengthening surveillance and controlling meningococcal disease in Latin America focus on improving: a) laboratory capabilities for diagnostic testing; b) communication regarding epidemiologic- and laboratory-based analyses; c) communication during outbreaks; d) monitoring of long-term disease outcomes; e) knowledge of vaccines against serogroup B disease; and f) criteria for defining and controlling meningococcal outbreaks. Overall, improving surveillance will help guide strategies for meningococcal disease prevention and control in Latin America.

Existen distintas oportunidades para reforzar los procedimientos de vigilancia de la enfermedad meningocócica entre los países de América Latina y dentro de ellos. En agosto del 2015, se llevó a cabo un taller en la ciudad de São Paulo (Brasil) en el que se trataron los siguientes puntos: 1) examen de la carga de la enfermedad meningocócica y el uso de la vacuna en América Latina; 2) evaluación de la eficacia de los actuales procedimientos de vigilancia de la enfermedad meningocócica en la región; 3) especificación de los retos para la vigilancia de la enfermedad meningocócica en la región; y 4) definición de los pasos para fortalecer los procedimientos de vigilancia de la enfermedad meningocócica y el control de esta enfermedad en la región. Como resultado del taller se formularon recomendaciones para reforzar los procedimientos de vigilancia y control de la enfermedad meningocócica en América Latina que hacían hincapié en mejorar: a) las capacidades de laboratorio con respecto a las pruebas diagnósticas; b) la comunicación sobre los análisis epidemiológicos y de laboratorio; c) la comunicación durante los brotes; d) el seguimiento de las consecuencias de la enfermedad a largo plazo; e) el conocimiento sobre las vacunas contra la enfermedad causada por el serogrupo B; y f) los criterios para definir y controlar los brotes meningocócicos. En términos generales, la mejora de los procedimientos de vigilancia ayudará a delinear las estrategias para la prevención y el control de la enfermedad meningocócica en América Latina.

Existem oportunidades para o reforço da vigilância da doença meningocócica entre os países e em cada país na América Latina. Em agosto de 2015, foi realizado um seminário na cidade de São Paulo, Brasil, com os seguintes objetivos: 1) avaliar a carga da doença meningocócica e o uso da vacina na América Latina; 2) avaliar a eficácia das atuais práticas de vigilância da doença meningocócica na Região; 3) identificar os desafios para a vigilância meningocócica na Região e 4) definir medidas para reforçar a vigilância da doença meningocócica e o controle da doença na Região. Partindo dos debates realizados durante o seminário, foram feitas as seguintes recomendações para reforçar a vigilância e o controle da doença meningocócica na América Latina, dando-se ênfase a melhorar: a) a infraestrutura laboratorial para exames diagnósticos; b) a comunicação das análises epidemiológicas e laboratoriais; c) a comunicação nos surtos; d) o monitoramento dos desfechos da doença a longo prazo; e) o conhecimento sobre as vacinas contra o meningococo do sorogrupo B e f) os critérios para definir e controlar os surtos de doença meningocócica. Em geral, a melhoria da vigilância contribuirá para orientar as estratégias para prevenção e controle da doença meningocócica na América Latina.

Country Ownership And Gavi Transition: Comprehensive Approaches To Supporting New Vaccine Introduction.

Since the mid-2000s low- and lower-middle-income countries have been focusing on developing and using evidence for immunization policy making, with an increasing emphasis on cost-effectiveness analysis, program costing, and financial flows-particularly for the introduction of newer, more expensive vaccines. While this is critical to informing decisions, countries still need to increase national immunization investment and explore innovative approaches to augment financing of immunization programs. The need for increased financing is especially strong in countries transitioning from support by Gavi, the Vaccine Alliance. With increased fiscal space to finance health and immunization programs as a result of improved economic performance, low- and lower-middle-income countries can reach the health status enjoyed by wealthier nations within a generation. However, new strategies and approaches related to domestic resources for immunization programs are needed to achieve this goal. Governments will need to increase their investments and modify existing external immunization financing arrangements if country ownership of immunization programs and the full promise of new vaccines are to be realized.

Combining Global Elimination Of Measles And Rubella With Strengthening Of Health Systems In Developing Countries.

Global efforts to eliminate measles and rubella can be combined with other actions to accelerate the strengthening of health systems in developing countries. However, there are several challenges standing in the way of successfully combining measles and rubella vaccination campaigns with health systems strengthening. Those challenges include the following: achieving universal vaccine coverage while integrating the initiative with other primary care strategies and developing the necessary health system resilience to confront emergencies, ensuring epidemiological and laboratory surveillance of vaccine-preventable diseases, developing the human resources needed to effectively manage and implement national strategies, increasing community demand for health services, and obtaining long-term political support. We describe lessons learned from the successful elimination of measles and rubella in the Americas and elsewhere that strive to strengthen national health systems to both improve vaccine uptake and confront emerging threats. The elimination of measles and rubella provides opportunities for nations to strengthen health systems and thus to both reduce inequities and ensure national health security.

ProVac Global Initiative: a vision shaped by ten years of supporting evidence-based policy decisions.

INTRODUCTION: The Pan American Health Organization (PAHO) created the ProVac Initiative in 2004 with the goal of strengthening national technical capacity to make evidence-based decisions on new vaccine introduction, focusing on economic evaluations. In view of the 10th anniversary of the ProVac Initiative, this article describes its progress and reflects on lessons learned to guide the next phase. METHODS: We quantified the output of the Initiative's capacity-building efforts and critically assess its progress toward achieving the milestones originally proposed in 2004. Additionally, we reviewed how country studies supported by ProVac have directly informed and strengthened the deliberations around new vaccine introduction. RESULTS: Since 2004, ProVac has conducted four regional workshops and supported 24 health economic analyses in 15 Latin American and Caribbean countries. Five Regional Centers of Excellence were funded, resulting in six operational research projects and nine publications. Twenty four decisions on new vaccine introductions were supported with ProVac studies. Enduring products include the TRIVAC and CERVIVAC cost-effectiveness models, the COSTVAC program costing model, methodological guides, workshop training materials and the OLIVES on-line data repository. Ten NITAGs were strengthened through ProVac activities. DISCUSSION: The evidence accumulated suggests that initiatives with emphasis on sustainable training and direct support for countries to generate evidence themselves, can help accelerate the introduction of the most valuable new vaccines. International and Regional Networks of Collaborators are necessary to provide technical support and tools to national teams conducting analyses. Timeliness, integration, quality and country ownership of the process are four necessary guiding principles for national economic evaluations to have an impact on policymaking. It would be an asset to have a model that offers different levels of complexity to choose from depending on the vaccine being evaluated, the availability of data, and the time frame of the decision. CONCLUSION: Decision support for new vaccine introduction in low- and middle-income countries is critical to maximizing the efficiency and impact of vaccination programs. Global technical cooperation will be required. In the future, PAHO and WHO have an opportunity to expand the reach of the ProVac philosophy, models, and methods to additional regions and countries requiring real-time support. The ProVac Global Initiative is proposed as an effective mechanism to do so.

Evidence-based decision-making for vaccine introductions: Overview of the ProVac International Working Group's experience.

INTRODUCTION: Pan American Health Organization's (PAHO) ProVac Initiative aims to strengthen countries' technical capacity to make evidence-based immunization policy. With financial support from the Bill and Melinda Gates Foundation, PAHO established the ProVac International Working Group (IWG), a platform created for two years to transfer the ProVac Initiative's tools and methods to support decisions in non-PAHO regions. METHODS: In 2011, WHO Regional Offices and partner agencies established the IWG to transfer the ProVac framework for new vaccine decision support, including tools and trainings to other regions of the world. During the two year period, PAHO served as the coordinating secretariat and partner agencies played implementing or advisory roles. RESULTS: Fifty nine national professionals from 17 countries received training on the use of economic evaluations to aid vaccine policy making through regional workshops. The IWG provided direct technical support to nine countries to develop cost-effectiveness analyses to inform decisions. All nine countries introduced the new vaccine evaluated or their NITAGs have made a recommendation to the Ministry of Health to introduce the new vaccine. DISCUSSION: Developing countries around the world are increasingly interested in weighing the potential health impact due to new vaccine introduction against the investments required. During the two years, the ProVac approach proved valuable and timely to aid the national decision making processes, even despite the different challenges and idiosyncrasies encountered in each region. The results of this work suggest that: (1) there is great need and demand for technical support and for capacity building around economic evaluations; and (2) the ProVac method of supporting country-owned analyses is as effective in other regions as it has been in the PAHO region. CONCLUSION: Decision support for new vaccine introduction in low- and middle-income countries is critical to guiding the efficient use of resources and prioritizing high impact vaccination programs.

Perspectives on the role of surveillance in eliminating rubella and congenital rubella syndrome in the Americas.

Effective management and coordination in regions currently lacking surveillance capacity will require significant increases in existing human resources to manage vitally needed expanded national surveillance systems. An adequate investment in human resources and infrastructure capacity is essential for ensuring surveillance functions well. This was the experience in the Americas, particularly with the recent elimination of rubella and congenital rubella syndrome. By taking this path, other benefits to the overall public health of the nations will occur. The purpose of this paper is to present perspectives on the role of surveillance in the elimination of rubella in the Americas and to share related perspectives on capacity development in developing countries. Hopefully, these perspectives will aid efforts to strengthen surveillance and advance rubella elimination in other regions of the world.

Genital human papillomaviruses among women of reproductive age in Jamaica.

OBJECTIVE: To characterize the prevalence and distribution of genital human papillomavirus (HPV) types among women in Jamaica, and to explore risk factors associated with HPV infection. METHODS: This was a cross-sectional study that took place in April-July 2010 with 852 sexually-active women, 16-49 years of age, who had attended a selected public or private primary health clinic in one of Jamaica's four health authority regions. Sociodemographic data was collected from each participant by trained study staff. Each participant had a gynecological examination that included a clinical Pap test and a cervical sample for HPV detection and typing-performed using the Research Use Only Linear Array (LA) genotyping assay (Roche Diagnostics Corp., Indianapolis, Indiana, United States). Overall and type-specific prevalence of HPV infection was calculated for 37 HPV types included in the LA genotyping assay. RESULTS: HPV DNA was detected in 460 of the 852 women (54.0%). Oncogenic HPV was detected in 297 women (34.9%) and HPV types 16/18 were found in 86 women (10.1%). The most frequently occurring HPV types were: 16 (6.2%); 35 (6.0%); 62 and 83 (5.5%); 61 and 58 (5.4%); 84 (4.7%); 18 (4.3%); and, 66 and 81 (4.2%). HPV prevalence was highest among women who were single, young (16-19 years), and had had more than three sexual partners in their lifetime. CONCLUSIONS: These results, coupled with high rates of cervical cancer, support introducing HPV vaccines while maintaining and strengthening cervical cancer screening services. Policy decision-making that reflects these results is instrumental to establishing a comprehensive cervical cancer program in Jamaica.

Genital human papillomaviruses among women of reproductive age in Jamaica / Virus de los papilomas humanos genitales en mujeres en edad reproductiva de Jamaica

OBJECTIVE: To characterize the prevalence and distribution of genital human papillomavirus (HPV) types among women in Jamaica, and to explore risk factors associated with HPV infection. METHODS: This was a cross-sectional study that took place in April-July 2010 with 852 sexually-active women, 16-49 years of age, who had attended a selected public or private primary health clinic in one of Jamaica's four health authority regions. Sociodemographic data was collected from each participant by trained study staff. Each participant had a gynecological examination that included a clinical Pap test and a cervical sample for HPV detection and typing-performed using the Research Use Only Linear Array (LA) genotyping assay (Roche Diagnostics Corp., Indianapolis, Indiana, United States). Overall and type-specific prevalence of HPV infection was calculated for 37 HPV types included in the LA genotyping assay. RESULTS: HPV DNA was detected in 460 of the 852 women (54.0%). Oncogenic HPV was detected in 297 women (34.9%) and HPV types 16/18 were found in 86 women (10.1%). The most frequently occurring HPV types were: 16 (6.2%); 35 (6.0%); 62 and 83 (5.5%); 61 and 58 (5.4%); 84 (4.7%); 18 (4.3%); and, 66 and 81 (4.2%). HPV prevalence was highest among women who were single, young (16-19 years), and had had more than three sexual partners in their lifetime. CONCLUSIONS: These results, coupled with high rates of cervical cancer, support introducing HPV vaccines while maintaining and strengthening cervical cancer screening services. Policy decisionmaking that reflects these results is instrumental to establishing a comprehensive cervical cancer program in Jamaica.

OBJETIVO: Determinar la prevalencia y la distribución de los tipos de virus de los papilomas humanos (VPH) genitales en las mujeres de Jamaica y explorar los factores de riesgo asociados con la infección por VPH. MÉTODOS: Este estudio transversal se llevó a cabo de abril a julio del 2010. Participaron 852 mujeres sexualmente activas, de 16 a 49 años de edad, que acudieron a uno de los consultorios públicos o privados de atención primaria seleccionados en cada una de las cuatro autoridades sanitarias regionales de Jamaica. Personal capacitado del estudio recopiló datos sociodemográficos de cada participante. Todas las participantes fueron sometidas a un examen ginecológico que comprendía una prueba clínica de Papanicolaou y la obtención de una muestra del cuello uterino a efectos de detectar y tipificarlos VPH mediante la prueba de genotipado Linear Array (LA) (Roche Diagnostics Corp., Indianápolis, Indiana, Estados Unidos), de uso exclusivo en investigación. Se calcularon las prevalencias global y específica de tipo de la infección por VPH para los 37 tipos de VPH incluidos en la prueba de genotipado LA. RESULTADOS: Se detectó ADN de VPH en 460 de las 852 mujeres (54,0%). Se detectaron VPH oncógenos en 297 mujeres (34,9%), y VPH de los tipos 16 y 18 en 86 mujeres (10,1%). Los tipos de VPH detectados con mayor frecuencia fueron 16 (6,2%), 35 (6,0%), 62 y 83 (5,5%), 61 y 58 (5,4%), 84 (4,7%), 18 (4,3%), y 66 y 81 (4,2%). La prevalencia de VPH fue más elevada en mujeres solteras, jóvenes (de 16 a 19 años) y que habían tenido más de tres compañeros sexuales en sus vidas. CONCLUSIONES: Estos resultados, junto a las elevadas tasas de cáncer cervicouterino, fundamentan la introducción de las vacunas contra el VPH al tiempo que se mantienen y refuerzan los servicios de tamizaje del cáncer cervicouterino. Las decisiones políticas que se adopten como consecuencia de estos resultados serán determinantes para establecer un programa integral contra el cáncer cervicouterino en Jamaica.

Strengthening surveillance: confronting infectious diseases in developing countries.

Effective management and coordination in regions currently lacking surveillance capacity will require significant increases in existing human resources to manage vitally needed expanded national systems. An adequate investment in human resources is essential for ensuring surveillance functions well. This was the experience in the Americas. By taking this path, other benefits to the overall public health of nations will occur. Monitoring deaths will help as an indicator for impending epidemics or other threats. Better equipped labs will detect antigen shifts in virus and circulating bacterial serotypes more rapidly and other earlier changes in patterns of transmission more efficiently. Any strategy must promote and galvanize the commitment of countries to excellence, equity, and access, above all.