Vaccine Concerns in the Developing World

Are people in developing countries really desperate for vaccines? Do they really walk for hours to get their children vaccinated. Maybe they do. But clearly, not everyone in the developing world is a believer. In fact, as you’re about to read, some are vaccinated at gunpoint…

Philippines

In 2015, more than 80% of people in the Philippines strongly agreed with the statement that vaccines are safe. A more recent poll in 2018, found that only 20% of people in the Philippines agreed with the statement. In 2015, 82% of people were confident in the effectiveness of vaccines, but in 2018, only 22% felt that vaccines are effective [1]

What happened in the Philippines between 2015 and 2018, that so badly shook people’s faith in vaccines?

It seems the main driver was a disastrous dengue vaccine trial for Dengvaxia, which was given to more than 800,000 school-children (although numbers from different media outlets vary – from 720,000 up to 830,000), from early 2016 through to early 2018 [2].

The program was then suspended, but not before more than 3000 children were hospitalized [3] – some for dengue fever. As of September 2018, at least 150 deaths had been reported among children who received the vaccine, but authorities declared that many of those were due to pneumonia, leukemia, asthma, central nervous system infections, and therefore ‘occurred naturally’ [4].

More than 190,000 of those vaccinations were given without parental consent [5].

The public confidence in vaccines was so severely shaken by the disaster, that routine vaccination rates in children fell to 50%-60% in 2018. Seventy-seven percent of schoolgirls had received the first shot of HPV vaccine, but only 8% of schoolgirls got the second shot.

A supplemental vaccine drive, to raise measles vaccination rates, saw health workers going from door to door, and many mothers hid their babies. As little as 36% of babies in metro Manila region received the vaccine. The Department of Health Undersecretary remarked that “health workers would spend up to 30 minutes trying to convince parents to have their children vaccinated” [6].

Health secretary Francisco Duque III declared “If needed, they (health workers) must woo the parents to allow the DOH to administer vaccines on their kids” [7].

Thailand

In some provinces in Southern Thailand, vaccination rates are below 50%, as Muslim believers refuse vaccinations. Islamic leaders addressed the issue, by saying that “though some vaccines contain ingredients derived from pigs, which are forbidden for Muslims, it was more important for a good Muslim to remain in good physical health at all times”.

“Therefore, until alternative vaccines that do not contain haram ingredients are invented, Muslims may use vaccines without having to worry that they are violating the Islamic doctrine” [8].

The messages of support from religious leaders are displayed on health authority websites, in an effort to quell concerns, and promote vaccination. Despite vaccination teams visiting schools and homes, some parents signed letters declaring they would not receive vaccines – now, or in the future [9].

India

In an effort to persuade reluctant villagers to have their children vaccinated for polio, the Indian government and UNICEF also use religious leaders to increase vaccine uptake. Islamic leaders give speeches before Friday prayer services, using quotes from the Koran, to encourage their people to accept vaccines. Newspaper columns are prepared and signed off by religious leaders. They also conduct radio question-and-answer sessions to reassure hesitant parents [10].

Vaccine hesitancy in remote areas is hardly surprising. As one religious leader put it: “For decades, the government machinery has not reached out to them; there are no proper roads, no drainage systems, no employment opportunities, no basic facilities – and suddenly a team of health officials arrive there to say we care for your children and therefore we want to vaccinate them [10].

Uganda

In 2016, the Ugandan government announced a new law that would punish non-compliant parents with six months jail time. Anybody found making “public misleading statements about vaccinations could face two years in prison or a fine, under the same law”. A Ugandan baby must have an ‘immunization card’ in order to have their birth registered, and obtain a birth certificate. That immunization card must be shown in order to enrol at school [11].

One religious group in Uganda, known as Njiri Nkalu, are vehemently opposed to vaccines, believing in divine protection, rather than man-made vaccines. In 2016, health workers, along with armed police, forcefully entered their homes and vaccinated some 200 children. Many of the parents and children tried to flee into nearby sugarcane fields, but were rounded up and vaccinated for polio. One member was heard to say: “We don’t see why you bring all these guns to harass us. Our children are protected by God and we don’t need polio vaccines” [12].

At least ten members of the group were detained by police, but later released without charge [13].

The officers also forcefully entered the homes of Tabliq Muslims who had refused vaccines for their children. The District Commissioner, who accompanied the officers, said “Although the operation was a success, there are those who were tipped off and disappeared into the bushes with their children. We shall come back to get them” [12].

Nigeria

In 2003, three states in Northern Nigeria boycotted the oral polio vaccine, due to the alleged discovery of contaminants, including trace amounts of estrogen. The boycott lasted for 15 months [14].

Today, many in the African nation still remain deeply suspicious about the true motive of aggressive vaccination programs. One group is the infamous Boko Haram (which translates to ‘Western education is forbidden’), who came to the world’s attention in 2014, when it was reported they had kidnapped 276 school-girls.

It is too dangerous for vaccinators to go into Boko Haram-held territory during national immunization days, but they do manage to get those who are leaving, or fleeing the area…” At the bus stations, and the state and national border crossings, the lunchbox-toting teams (the polio vaccines are packed into lunchboxes) are there. Peering into cars, lifting the cloaks of women perched on motorbikes to find the babies strapped to their fronts and backs. Squeezing in the little vials of vaccine.

“If they say no, then we tell them they can go back,” said superintendent of immigration, Charles Tashllani, imposing order on Nigeria’s border with Niger in Katsina. Here, late in the evening, the Polio Emergency Operations committee reviews the campaign’s first day, which has seen 3,661 teams immunise 28,882 underfives. The detail is such that eight missing marker pens are on the agenda, as is the sacking of two town announcers who did not inform people about the programme” [15].

But it’s not just extremists who have their doubts. Media reports over the years, reveal that hundreds of parents have been threatened with jail time and prosecution [16].

Pakistan

In 2015, more than 500 parents were arrested by police in Pakistan, for not allowing their children to have the polio vaccine. They could be released on bail, only if they signed an affidavit that they would allow their children to get the vaccine.

A UNICEF team leader in Pakistan explained that “First the workers (try to) convince them, then their supervisors, then senior members of the community”. If all that coercion and intimidation fails, and the parents still resist, then the police are called to arrest them” [17].

Earlier this year, a health worker was murdered, trying to persuade a man to let his children have the oral polio vaccine [18]. This comes amidst reports of an angry mob of parents setting fire to a hospital, after school-children were vaccinated, and 75 students later fell sick. Doctors denied the illness was due to vaccines, and suggested they probably felt sick due to their parent’s anxiety about vaccines [19].

China

In January, 2019, hundreds of parents in Jinhu, China, marched in the streets, demanding an explanation for the expired vaccines given to their children. More than 100 children had suffered fevers, skin rashes, and vomiting – some for months on end – since receiving the vaccines.

“Local authorities eventually found that an entire batch of vaccines was used instead of being destroyed”. Parents claimed the same kinds of reactions had been occurring for at least 10 years, and believe expired and faulty vaccines had been used for years.

Riot police from neighbouring counties were brought in to quench the protests, and authorities banned both regular and social media from reporting on ‘inflammatory’ news about vaccines [20].

It is just one, on a growing list, of vaccine scandals and controversies in China, with many parents declaring they have lost faith in China-made vaccines [21].

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References:

[1] Larson HJ, Hartigan-Go K, de Figueiredo A, Vaccine confidence plummets in the Philippines following dengue vaccine scare: why it matters to pandemic preparedness, Human Vaccines & Immunotherapeutics, 2018.

[2] Newey S, Trust in vaccines plummet following dengue scandal in Philippines, The Telegraph, 12th October 2018, https://www.telegraph.co.uk/news/0/trust-vaccines-plummet-following-dengue-scandal-philippines/. Accessed March 2019.

[3] DOH: Over 3000 students hospitalized after dengue shot, Rappler, 13th April 2018, https://www.rappler.com/nation/200187-doh-students-hospitalized-dengvaxia. Accessed March 2019.

[4] Tomacruz S, 19 out of 154 kids died of dengue despite Dengvaxia shot, Rappler, 26th September 2018, https://www.rappler.com/nation/212904-doh-report-number-children-dead-dengue-dengvaxia-shot-september-2018. Accessed March 2019.

[5] ABS-CBN News, Failon Ngayon: Dengvaxia, Available on youtube, https://www.youtube.com/watch?v=AQObs3vk3l0 (see at 5:39), Accessed March 2019.

[6] Tomacruz S, Parents still scared of govt’s free vaccines a year after Dengvaxia scare, Rappler, 27th September 2018, https://www.rappler.com/nation/212927-child-vaccination-rate-philippines-as-of-september-2018#cxrecs_s. Accessed March 2019]

[7] Cepeda M, Duque to health workers: ‘Woo’ parents to avail of vaccination programs, Rappler, 21st Febrary 2018, https://www.rappler.com/nation/196551-duque-health-workers-woo-parents-vaccination. Accessed March 2019.

[8] Rujivanarom P, ‘Vaccine Denial’ Behind Measles Deaths in the South, The Nation, Thailand Portal, http://www.nationmultimedia.com/detail/national/30356655. Accessed February, 2019.

[9] Vejpongsa J. Muslim concern about vaccine fuels Thai measles outbreak, AP News, 6th November, 2018.

[10] Pisharoty S. Interview: Muslim clerics to address misconceptions on ongoing measles-rubella vaccine drive, The Wire, 24th April, 2017.

[11] Global Press News Service, Anti-vaccine parents in Uganda face jail time under new law, The Seattle Globalist, 23rd August 2016.

[12] Yolisizira Y. 10 arrested over polio immunization, The Monitor, 3rd June 2016. As of 29th June, this article is still available online, at: https://www.monitor.co.ug/News/National/10-arrested-polio-immunisation/-/688334/3186268/-/view/printVersion/-/11q2sgd/-/%2523.

[13] Uganda 2016 International Religious Freedom Report, https://www.state.gov/documents/organization/268952.pdf Accessed March, 2019. (Note: This document has since been moved or removed from the State Department website, despite both the 2015 and 2017 reports still being available…)

[14] ABC News. Vaccine Boycott Grows in Northern Nigeria, 24th February, 2004.

[15] McVeigh T. Nigeria battles to beat polio and Boko Haram, The Guardian, 7th May 2017.

[16] Hundreds of Nigerian parents refuse polio vaccines, The Star, 2nd August 2011, https://www.thestar.com/news/world/2011/08/02/hundreds_of_nigerian_parents_refuse_polio_vaccines.html. Accessed March 2019.

[17] Saifi S, Botelho G. Over 500 Pakistani parents arrested for children’s failure to get polio vaccine, CNN, 4th March 2015.

[18] Farmer B. Polio worker gunned down in Pakistan trying to persuade family to vaccinate children, The Telegraph, 9th April 2019.

[19] Farooq Khan O. People set hospital afire in Peshawar, Times of India, 23rd April 2019.

[20] Police and parents clash in Jiangsu after 145 children get sick from expired vaccines, Asia News, 11th January 2019, http://www.asianews.it/news-en/Police-and-parents-clash-in-Jiangsu-after-145-children-get-sick-from-expired-vaccines-45954.html. Accessed March 2019.

[21] Leng S, Huang K. As new vaccine scandal grips China, parents say they have lost faith in the system, South China Morning Post, 22nd July, 2018.

The Truth About Vaccines & Other Drugs in Africa

There seems to be a perception in the Western world that African children are dying due to lack of vaccines, but is that actually true? Not exactly.

In many cases, the relentless push for vaccines (usually by outside interests) as a magic fix for disease, has come at the expense of other interventions.

According to UNICEF statistics, Rwanda has 95% – 98% vaccination coverage for diptheria-tetanus-pertussis…yet 37% of children are stunted due to malnutrition. Only 62% have access to proper sanitation [1]

Botswana has 95% children vaccinated with three doses of diptheria-tetanus-pertussis vaccine…but just over half receive Vitamin A supplementation (lauded in the early 1990’s as THE most effective health intervention of all), and only 20% of infants are exclusively breastfed [2].

Malawi is ranked 9th poorest country in the world, with more than half its people living below the poverty line, 9.6 million Malawians (more than half the population) don’t have access to a decent toilet, 5.6 million people (1 in 3) don’t have access to clean water, and 42% of children are stunted [3], yet more than 80% of children are up-to-date with vaccinations…[4].

The Malawi vaccination schedule now includes vaccines for measles, polio, cervical cancer, rotavirus, pneumococcal disease, diphtheria, tetanus, pertussis, hepatitis B, Haemophilus Influenza type B (Hib) [5].

According to UNICEF, almost 90 percent of child deaths from diarrhoeal diseases are directly linked to contaminated water, lack of sanitation, or inadequate hygiene [6], but money that may have been spent on sanitation and procurement of clean water, is spent on rotavirus vaccines instead.

Also, recall that the diptheria-tetanus-pertussis vaccine used in poor African countries is likely the old whole-cell thimerosal-containing vaccine, due to being cheaper than the new acellular vaccine [7].

African countries are increasingly rolling out HPV vaccination campaigns for school-girls. While it’s true that the majority of cervical cancer cases are in developing countries, one can’t help but wonder if HPV vaccination is a wise use of resources, given the more pressing needs in many sub-saharan countries.

In 2011, Merck donated 2 million doses of Gardasil vaccine to Rwanda, and 95% of the nation’s 11-year-old girls were vaccinated. The freebies ran out after three years, at which time Merck offered the vaccine to the Rwandan government at ‘discount prices’. Such donations can have the effect of locking governments into programmes which they later have to fund themselves, at the expense of more pressing issues, and may be more about ‘priming the market’, than charity on the part of the drug company [8-9].

Between 2013 – 2016, 26, 766 young girls in Malawi were given quadrivalent HPV vaccination as part of a pilot project, supported by GAVI – and 2051 girls who participated were under the age of 9 [10].

Vaccination coverage in Tanzania in 2014 for school and out of school girls was estimated at 93 per cent and 92.6 per cent, respectively. The chief Health Minister boasted that, despite “heartbreaking stories of the ill effects of vaccines” online, Tanzania had not even registered one single adverse reaction from the vaccine [11]. Is there an incentive for African governments – hopeful of foreign investment from pharmaceutical companies to downplay risks and reactions, in order to keep up the flow of income?

In December 2012, 500 children in Chad received a new experimental meningitis vaccine, and 38 children were later hospitalized, with 7 of the children flown to Tunisia for specialized treatment. The Chadian government declared their “state of health is not worrying”, but other sources in Chad claimed the children were paralysed [12-13].

In 2008, the Center for Research on Multinational Corporations reported (among others) the case of clinical trials in Uganda between 1997 – 2003, where thousands of women suffered adverse reactions to the drug Nevirapine, and some died – and all of it went unreported, while testing continued [14].  

Supplemental Immunization Activities

In addition to routine childhood vaccines, WHO and other agencies also conduct ‘supplemental immunization activities’, which are mass vaccination campaigns that aim to administer extra doses of vaccines. According to the WHO, there have been “thousands of these supplementary vaccination campaigns” with oral polio vaccine since the 1980’s, with children vaccinated regardless of prior vaccine history. The extra doses were not recorded on the child’s health cards [15].

Extra doses of measles vaccines are also given. A quick look at the Measles and Rubella Initiative Calendar for 2019 shows they plan on supplementally vaccinating more than 100 million people in sub-Saharan Africa this year – in addition to routine vaccinations [16].

Experimental Vaccines

In addition to routine vaccinations and supplementary vaccination, poor African countries are increasingly used to test experimental vaccines because it’s quicker and cheaper and less stringent regulations than western countries “Development cycles can be reduced thanks to the faster recruitment of subjects from a larger pool of patients. The costs of recruiting patients and paying investigators are lower too” [17]

This poses some real ethical problems. I have never been to Africa but I have lived in a developing country, and witnessed first-hand the reverence given to those who are in positions of power, or overseas-trained. People are too embarrassed or intimidated to ask questions of their doctor or report side-effects, as it would seem disrespectful and ‘out of line’ with the societal and cultural hierarchy.

Other developing regions face similar issues. M. Nabeel Ghayur, a pharmacologist who worked in drug development in Pakistan says: “People actually have blind trust in their doctor in South Asia. They have no idea what drug development is, they have no idea what clinical trials are.

He said there was little red tape in those countries, and that people would rarely ask about drug side effects and legal issues” [18].

Starting next month (March, 2019), 750,000 babies in Kenya, Ghana and Malawi will be given a new experimental malaria vaccine. The vaccine Mosquirix will be given to children in four doses- at six, seven, nine and 24 months through an injection on the upper arm [19].

 The Star newspaper in Kenya reported: “Mosquirix, also called RTS,S, was first conceived in the 1980s and has undergone all clinical trials, returning less than optimal results.

The vaccine – made by GSK – is only effective in 30 to 50 per cent of patients, says the WHO.

Its effectiveness diminishes over time and it disappears fastest in children who are most exposed to malarial mosquito bites. However, because no defence against malaria is perfect, the vaccine is being considered in addition to the existing defences” [20].

GlaxoSmithKline and its backers, including Bill and Melinda Gates Foundation, had already spent $565 million on developing the drug, which brought back disappointing results in early testing, and did not meet the expected criteria for a malaria vaccine set out by a WHO-led consortium”, which requires a “protective efficacy of more than 50% against severe disease and death, and last longer than one year.” [21]

In 2017, the Global Task Force on Cholera Control launched a very ambitious set of goals, including 90% reduction in cholera deaths by 2030. Naturally, vaccines feature prominently, namely the oral cholera vaccine. A year later, the ‘largest vaccination drive in history’ took place, with over 2 million people vaccinated for cholera in Zambia, Uganda, Malawi, South Sudan and Nigeria [22].  

As of January 2019, more than 66,000 people in the Democratic Republic of Congo have been vaccinated with Merck’s V920, an experimental Ebola vaccine [23].

A Chinese-made genetically-engineered Ebola vaccine was given to 500 adults in Sierra Leone in 2015, as part of a Phase II trial. The Chinese FDA then approved the vaccine, without any Phase III trials [24].

In 2018, some 20,000 Malawian children were enrolled to receive an experimental typhoid conjugate vaccine [25].

Supplemental Drugs

In addition to routine vaccines, supplemental vaccines and experimental vaccines…many African children (and pregnant women) are also given supplemental drugs – malaria (sulfa) drugs, three times during the first year of life (starting from 10 weeks old), or several times per year during childhood – even if they have no infection [26]. During pregnancy, mothers are given the drugs at least three times during the 2nd and 3rd trimesters – again, even if they have no infection [27].

This is called “intermittent preventive therapy”, and it was promoted aggressively by the Bill and Melinda Gates Foundation, to the tune of at least $28 million dollars, with the establishment of the ‘IPTi Consortium’ [28].

in 2008, a technical advisory group at the World Health Organization (who coincidentally has received more than $2.4 billion in donations from the Bill and Melinda Gates Foundation, since 2000 [29], including a $1.2 million grant in 2006, with the express purpose of ensuring “that the IPTi consortium outcomes are collated, assessed by international experts, and result in a WHO policy recommendation” [30])  failed to recommend the program, due to concerns over safety and efficacy.

The protests from the Gates Foundation and their scientists were so loud and insistent, it prompted WHO malaria chief to write a memorandum (which was later leaked to newspapers) to WHO director, Margaret Chan, saying: “although it was less and less straightforward that the health agency should recommend IPTi, the agency’s objections were met with intense and aggressive opposition from Gates-backed scientists and the foundation…” [31]

Not to be deterred, the Gates Foundation then donated funds to have the Institute of Medicine conduct another review, chaired by a doctor whose work has received at least $50 million in funding from the Gates Foundation [32].

Predictably enough, the IOM review concluded that “an intervention with results of this magnitude is worthy of further investment as part of a public health strategy to decrease morbidity from malaria infections in infants“, although they noted that “time and resources did not allow independent audits of trial conduct, data management, or analysis” [33].

The WHO malaria chief who protested the excessive influence of the Gates Foundation, was later replaced…by a member of the Gates-founded IPTi Consortium (and now Vice-President of Johnson & Johnson pharmaceutical company [34]) and WHO then proceeded to recommend these sulphonamide drugs to infants ( given at the same time as routine vaccines for diptheria-tetanus-pertussis and measles), children and pregnant mothers, despite evidence of increasing drug-resistance in sub-Saharan Africa…

Prior to the IPTp and IPTi programs, pregnant women in malaria-endemic areas of Africa were given weekly doses of chloroquine, until drug resistance and compliance issues made it unfeasible to continue [35].

Other chemical exposures

The use of DDT to control mosquitos in malaria-endemic areas was endorsed by the World Health Organization in 2006, and its use has been increasing ever since. The chemical is sprayed inside homes and buildings – according to a report by the United Nations Environment Program, at least 3952 tonnes of DDT were sprayed in Africa and Asia in 2007 [36].

Agricultural spraying of DDT is common in Africa, especially in West Africa, where mosquitos have developed resistance to it [37].

The vast wealth of precious metals and natural resources in Africa have been both a blessing and curse to its people. Gold and other mining in Africa have produced countless mountains of toxic wastes that pollute the air, soil and water, most notably with uranium, arsenic and lead [38].

Another form of pollution experienced in poorer parts of the world, such as sub-Saharan Africa, is indoor air pollution from cooking over open fires, using wood, charcoal, kerosene or animal dung. The World Health Organization estimates that as many as 3.8 million people die prematurely every year, due to health conditions caused by indoor air pollution, the majority due to pneumonia [39].

References:

[1] UNICEF, Statistics: Rwanda https://data.unicef.org/country/rwa/. Accessed February, 2019

[2] UNICEF Statistics: Botswana, https://data.unicef.org/country/bwa/. Accessed February, 2019.

[3] WaterAid, Facts and Statistics: Malawi, https://www.wateraid.org/mw/facts-and-statistics. Accessed February, 2019.

[4] WHO, WHO and UNICEF Estimates of Vaccine Coverage, 2017 Revision, https://www.who.int/immunization/monitoring_surveillance/data/mwi.pdf, Accessed February, 2019.

[5] GAVI The Vaccine Alliance, Iceland pledges US $1 Million to Immunise Children in Malawi, https://www.gavi.org/library/news/statements/2019/iceland-pledges-usd1-million-to-immunise-children-in-malawi/, Accessed February, 2019.

[6] UNICEF, Press Release, Children Dying Daily Because of Unsafe Water Supplies and Poor Sanitation and Hygiene, New York: UNICEF, 2013.

[7] WHO, Biologicals: Pertussis, https://www.who.int/biologicals/vaccines/pertussis/en/. Accessed February, 2019.

[8] The Guardian, Drug donations are great, but should Big pharma be setting the agenda? https://www.theguardian.com/world/2013/apr/29/drug-company-donations-bigpharma. Accessed September, 2017.

[9] Editorial, Financing HPV vaccination in developing countries, The Lancet, 2011, 377(9777):1544.

[10] Msyamboza KP, et al, Implementation of a human papillomavirus vaccination demonstration project in Malawi: successes and challenges, BMC Public Health series, 2017, 17:599.

[11] AllAfrica, Tanzania: Cancer Vaccination Program Registers Success, https://allafrica.com/stories/201602152199.html, Accessed February, 2019.

[12] MedicalExpress, 38 children hospitalised after meningitis shot in Chad, https://medicalxpress.com/news/2013-01-children-hospitalised-meningitis-shot-chad.html#jCp. Accessed February, 2019][

[13] England C, Minimum of 40 children paralyzed after new meningitis vaccine, VacTruth, https://vactruth.com/2013/01/06/paralyzed-after-meningitis-vaccine/. Accessed February 2019

[14] Kelly S, Testing drugs on the developing world, The Atlantic, 27th February 2013, https://www.theatlantic.com/health/archive/2013/02/testing-drugs-on-the-developing-world/273329/. Accessed February, 2019.]

[15] Helleringer S et al, Supplementary polio immunization activities and prior use of routine immunization services in non-polio-endemic sub-Saharan Africa, Bulletin of the World Health Organization, 2012, https://www.who.int/bulletin/volumes/90/7/11-092494/en/. Accessed February, 2019.

[16] Measles and Rubella Initiative, SIA Schedule, https://measlesrubellainitiative.org/resources/sia-schedule/. Accessed February, 2019.

[17] Edwards M, R & D in Emerging Markets: A new approach for a new era, McKinsey & Company, 2010, https://www.mckinsey.com/industries/pharmaceuticals-and-medical-products/our-insights/r-and-38d-in-emerging-markets-a-new-approach-for-a-new-era. Accessed February, 2019.

[18] Joelving F Many drugs for US kids tested in poor countries, Reuters, 23rd August 2010, https://www.reuters.com/article/us-drug-tests-idUSTRE67M1VO20100823. Accessed February, 2019.

[19] Kulkani P, Malaria Vaccine trials in Africa: Dark saga of outsourced clinical trials continues, Newsclick, March 2018, https://www.newsclick.in/malaria-vaccine-trials-africa-dark-saga-outsourced-clinical-trials-continues, Accessed February 2019.

[20] Muchangi J, Kenyan children to get first malaria vaccine in the world next month, The Star,14th February, 2019, https://www.the-star.co.ke/news/2019/02/14/kenyan-children-to-get-first-malaria-vaccine-in-the-world-next-month_c1894869. Accessed February, 2019.

[21] Kulkani P, Malaria vaccine trials in Africa: Dark saga of outsourced clinical trials continues, Newsclick, 17th March 2018, https://www.newsclick.in/malaria-vaccine-trials-africa-dark-saga-outsourced-clinical-trials-continues. Accessed February, 2019.

[22] UNICEF, Global Task Force on Cholera Control marks a year of progress toward ending cholera worldwide, https://www.unicef.org/press-releases/global-task-force-cholera-control-marks-year-progress-toward-ending-cholera. Accessed February, 2019.

[23] Ward Hackett D, Ebola vaccinations expanding in Central Africa, https://www.precisionvaccinations.com/v920-ebola-vaccine-now-deployed-drc-uganda-and-south-sudan. Accessed February, 2019.

[24] Liu A, China approves domestic Ebola vaccine developed from recent outbreak, FiercePharma, https://www.fiercepharma.com/vaccines/china-approves-self-developed-ebola-vaccine-from-2014-outbreak-virus-type. Accessed February, 2019.

[25] Gordon M, Trial kicks off in Malawi: First child vaccinated with typhoid conjugated vaccine in Africa, http://www.coalitionagainsttyphoid.org/trial-kicks-off-in-malawi-first-child-vaccinated-with-typhoid-conjugate-vaccine-in-africa/. Accessed February, 2019.

[26] WHO, Intermittent Preventive Treatment in Infants, https://www.who.int/malaria/areas/preventive_therapies/infants/en/?fbclid=IwAR1yumPwTyZEqBUzCIlPatU8pafeR9qUbNBYTA-vf8_38iyhvAumqK7xTlE. Accessed February, 2019.

[27] WHO, Intermittent Preventive Treatment during Pregnancy, https://www.who.int/malaria/areas/preventive_therapies/pregnancy/en/. Accessed February, 2019.

[28] Bill and Melinda Gates Foundation, New grants to accelerate malaria research and development, https://www.gatesfoundation.org/Media-Center/Press-Releases/2003/09/Grants-for-Malaria-Research. Accessed February 2019.

[29] Huet N & Paun C, Meet the world’s most powerful doctor: Bill Gates, Politico, 4th May 2017, https://www.politico.eu/article/bill-gates-who-most-powerful-doctor/?fbclid=IwAR1t3JJlmxNRTqcZpgvo4dPAFtrZw5vknQJRd_4gDPaU06emIgnLGUtMl6s. Accessed February, 2019.

[30] Bill and Melinda Gates Foundation, How We Work: Grant, WHO, https://www.gatesfoundation.org/How-We-Work/Quick-Links/Grants-Database/Grants/2006/10/OPP37476. Accessed February, 2019.

[31] McNeil DG, Gates Foundation’s Influence Criticized, New York Times, 16th February 2008, https://www.nytimes.com/2008/02/16/science/16malaria.html?fbclid=IwAR1otqtbJWZ8t4lO-XIVDRfQmasdDlTR5Iy6BkjoCh65fDhCECvTazjIkAI. Accessed February 2019.

[32] VCU School of Medicine, Myron Levin M’67: A pioneer of the modern discipline of vaccinology, https://wp.vcu.edu/somdiscoveries/2017/05/myron-levine-m67-a-pioneer-of-the-modern-discipline-of-vaccinology/. Accessed February, 2019.

[33] [IOM, Committee on the Perspectives on the Role of Intermittent Preventive Treatment for Malaria in Infants, 2008, available at: https://www.who.int/immunization/sage/10_IOM_report_on_IPTi.pdf. Accessed February 2019.

[34] UW Dept of Global Health, Robert Newman, https://globalhealth.washington.edu/faculty/robert-newman. Accessed February 2019.

[35] Heymann DL, Antenatal chloroquine chemoprophylaxis in Malawi: chloroquine resistance, compliance, protective efficacy and cost, Trans R Soc Trop Med Hyg,.1990;84(4):496-8.] [Kayentao K et al, Comparison of Intermittent Preventive Treatment with Chemoprophylaxis for the Prevention of Malaria during Pregnancy in Mali, The Journal of Infectious Diseases, 2005, 191(1):109–116.

 [36] Cone M, Should DDT be used to combat malaria? Scientific American, 4th May 2009, https://www.scientificamerican.com/article/ddt-use-to-combat-malaria/. Accessed February 2019.

[37] WorldWatch, Malaria, Mosquitos and DDT, http://www.worldwatch.org/node/517. Accessed February. 2019.

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