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At the beginning of the 20th century, surviving childhood was a not a given. One out of every 10 American children died before their first birthday.

While childhood mortality rates sank like a stone in developed countries over the last century, those gains were slower to materialize in developing countries, in part because of a lack of access to vaccines. These life-saving tools are still a stretch, financially, for some low-income countries.

In recognition of that fact, a public-private partnership known as Gavi, the Vaccine Alliance, was established in 2000 to help poor countries gain access to the vaccines that the World Health Organization says every child should have.


The alliance currently helps 73 of the poorest countries in the world buy vaccines, some at heavily subsidized prices. Children from those countries make up 60 percent of the kids born every year.

Dr. Seth Berkley has been the Geneva-based organization’s CEO for the past five years. He sat down recently to tell STAT about Gavi and to discuss the underutilization of yellow fever vaccine, as well as the prospects for Ebola and Zika vaccines. This transcript has been edited for length and clarity.


How many types of vaccines do you distribute?

We now have 15 different vaccines that are being used, some of which are regional and some of which are for all children. WHO now has 11 vaccines that they suggest all children should have, plus HPV, which is obviously for adolescents.

Who pays for them?

There’s no free lunch here. Everybody pays something. So countries pay a very small amount, 20 cents [per vaccine dose], when they first come in as low-income countries. As they move into a lower-middle income [status] they then go up 15 percent per year, and that depends upon how fast they grow so it could be a long time or a short time.

And when they cross the threshold of $1,580 dollars [of gross national income], they then move into transition. And they have five years to take on the full cost of the vaccine.

What’s the philosophy around requiring countries to pay?

The idea is to focus our resources on the very poor countries who, realistically, within their financial envelope, could not afford these live-saving vaccines.

Where does your funding come from?

So we receive from numerous sovereign donors. The US, for example, is a big supporter of us. The UK. Norway. The Bill and Melinda Gates Foundation is a very, very large supporter. Bill was involved in the founding of GAVI — he’s been there from the beginning. So pretty broad support.

Do you think the ongoing large yellow fever outbreak in Angola and the Democratic Republic of Congo, which is stretching global vaccine supplies, will galvanize at-risk countries to make more of an effort to vaccinate against the virus?

I hope so.

It’s one thing to have a disease appear in a country that hasn’t experienced it before. But it’s another thing to have it part of the routine immunization but have very low coverage, and, therefore, have it not be effective. I think one of the challenges here is that countries need to really take it seriously and get coverage up.

This is a fabulous vaccine. It’s one-dose, lifetime, very effective, relatively inexpensive. So this is one where you really want to make sure there’s good coverage.

Yellow fever vaccine is made in eggs, an old and slow process. A more modern approach would allow for more rapid scale-up of production, when it’s needed. But a new yellow fever vaccine would cost a lot of money to bring to market. Who’s going to pay for that?

These are some of the debates that we’re having more broadly in infectious diseases. How do you put incentives in place to make sure these products are developed?

This is a whole new space for the world. Because traditionally most of the vaccines GAVI uses are vaccines that are used in the West, as well. There’s a [profitable] market to amortize the research into.

Let’s talk about Ebola. It’s great that there is finally evidence that one of the experimental vaccines, produced by Merck, protects people. Are you hopeful at this point?

Oh yes, I’m quite hopeful. And part of that is we have an agreement with Merck to move forward.

Our agreement with Merck had three components. One was for them to submit an emergency use authorization application to WHO, so that if there was an emergency, the vaccine would be ready to go. Second was to have 300,000 doses produced and ready to be used in case of an emergency. And then third was to submit an application for licensure by the end of 2017.

So I think that will happen. I think the bigger and more complicated issue is: How do we move to second-generation vaccines, and how do we move to vaccines that are idealized for prevention?

If our goal was to protect a health worker, for example, that might not be the ideal vaccine to use. Maybe one of the [two-dose] prime-boost regimes or something else might be a more effective way to get sustained antibodies.

And at the end of the day, this is an Ebola Zaire [vaccine]. Should we have an Ebola Zaire-Sudan-Bundibugyo, etc [vaccine]? Should we have a Marburg [vaccine]? So one of the issues is: What are the incentives in place to get companies to move for a next generation vaccine?

Has the world figured out how to create a system where vaccines that don’t have a traditional market — but for which there is a huge need — are developed?

Donors have not been necessarily lining up to provide support. Some have been interested and are going to help.

But one of the issues … we need to make sure that people understand is that if we don’t pay for vaccines when we ask companies to put the effort in, then they’re not necessarily going to be there the next time or the next time.

So it really comes down to a risk appetite. If we want to have the companies engaged, if we want to have the vaccines available, we have to be willing to pay for them.

Now, there’s a contract there. If the companies aren’t willing to throw in their effort, it becomes a problem. In other words, if this were seen as a “Let’s get maximum prices during these [emergency] periods,” I think people would be quite upset about that.

But I think, on the other hand, if companies are going to step up to the plate and do something, they need to be remunerated for their work. Otherwise, we’re going to have a problem with engaging them in the future.

What do you think the prospects are for a Zika vaccine?

I think technically it doesn’t look like that agent is going to be that hard. I think the bigger problem is we didn’t have animal models for it [Zika infection].

We were lucky with Ebola that we had vaccine candidates already made and we had reasonable animal models. We knew you could get protection in animal models. So it was easy to then accelerate products. But here, you’re really struggling a little bit.

So it’s sounding like a Zika vaccine is not in the near-near term?

It’s certainly not in the near-near term.

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